HomeMy WebLinkAboutKEN DELLINGER INTERNET ACCESS.TIFMar 05 09 10:40a Ken Dellinger Builder 7048278209
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CATAW BA COUNTY
P.O. Box 399
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T3UTT.D1NG SEE ( S
Newton, NC Ztlb&d
Fax Number (879) 465 -8962 Newton Offiuo
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PLRMIT CENTER
Fim Number (82x)322- LS14IlickoryOffice
OffiM➢honc Number (828) 465 -8399
Contractor Information for
Internet access
If applicant holds multiple licenses, a separate application must be submitted for each license.
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ALL FIELDS MUST BE COMPLETED OR THE APPLICATION WILL BE REJECTED
Company name as listed on state license: k ?�91 _ .. �� : �/ '�' r'
License holders name as listed on State License:
(If different frofn Company name)
(First Name)
(M) (Last Name)
License Number: A OC215 _ 4 6 Lie. Expiration Date:
Address: �� � 11 /- / (A)
[ -mail address: !� lik ..�� a • Geiyt
(C mail addresses will be used for notification)
Telephone: 1 7D` AA ! — J 1 ` u /
Fax Number: � a / 9 A G (�
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Mobilc Ccll: 7 ��O 1 O 3-
Name(s) of any other Qualifier listed on the license:
Name(s) of any other person that is authorized to sign for a permit with Catawba County:
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Signature of applicant: Date: • `� "� �
By signing this application, you agree_ Lo maintain the security of the log -in name and password.
Password security will be the full responsibility of the applicant.
The issuance of a log -in and password will allow a person to schedule inspections for all projects they
are listed on as a contractor. Your User name and temporary password will be sent to the email
address you provided above after the information on this form is verified. This form can be mailed to
the address or either of the fax numbers listed above.
17/18/2007