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Contractor Information for Intemet Access
If applicant holtla multiple licensees. a eepande appfcation swathe submitted for Seth Ikame,
ALL FIELDS MUST BE COMPLETED OR THE APPLICATION 7 NMLL ECTED
Company name as listetlon Sate license: Calencd� �ecf(-ttdl Carl 1Yl O y�!1L
License holdersnemeM listed on Slate License: h . G(rh y�ur -�
(IldiRerent from Company None) (First Name) (M) (Last Name)
License Number. u 4i4 ia- i I License Expiration Date:
Address: b/'IVpi
M_nor - sTy� I[IP, tyc �Stl7
E -mail addmaa:
C4
Y'N4mchcfs�Y�000�Com
(E addresses wiN be for nolficatlanl
Telephone:
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70 A/ - .20 /- 50t;G
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Fax Number
7q�- 799-908 /7
Mobile Cott:
7o 4 1- - oj 0/- 7
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Name(s) of any other Qualifier listen on the
Name(s) of any other peROn that le aumort¢d b Ggn for a prntit whh Cala County:
- �rnn�� oroo/ {c Secr�tre�I
Signature of a ppbwm: ) -.?7 -0 9
fN 5lpning Inia epplirathn, you ague b mamas me fauriry�f
the Wl" rreme and pauavm '
paaanwd secusywaf be me full responsfbffley Of the applicant.
The leewMx:F da ing -lo end Mn M h elfmu a person to schedule Inspections br all projects
they are listed on as a nonttaebr. Your Ikier name and Mmperani pwawrd win he som b er
smell un can you pewPoe a Odom" Information on Ns%bmt ts yedflatl.
Tide farm can ad, mailed b t eddnp ar g itlrx d tlr fee mm�ors Ilred above.
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