HomeMy WebLinkAboutJAMES OXYGEN INTERNET APPLIC.TIFJar. 26. 2;09 9:39AM James 0x ygen d upcly Co.
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Contractor Information for Internet access
If appBnnt holds multiple ucerrsc, a eeparateapplfcation mustbe submitted for eadl license.
A FELOSMVSIBECOMPLETED - ORR THE APPVCATION WILL BE REJECTED n�a
Ca m pan y name as listed on state license: Jt P+�I�_ le§( Ura+9arn✓
❑tense holders name as lined on state License: borgxw Ld FTl
(B different from Company rume) _ .(first Name) (M) Ilan Nam
License Num C ! Ve Expiation Date. ��0
Address: P.o. I1 DL Li
C�( dls603
Emailaddress: Are 10Q'6406(ar ' A wow
p (E-mail addresses will be used for notifi cation)
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Telephone: gr .A;�?'S$�j.
Fax Number 90e zap / -,$ZG y
Name(s) of any other Qualifier lined on the Icensa:
Name(s) of any other person that Is authorized to sign for a permit with Catawba County:
Tomfss; - RnnM14,
for
Iw �odlat' n ae 0
signature of applinm: .LA4�C O .0 Date: I'eZ(p
By signing this application, you agreeto manuin t9 se rhyaf the login name and password.
Password security will be the full responsibility of the applinm.
Tire issuance of aioain and password will alloev a person tp schedule Impactions for all pmiexts they
are listed on az a ceMmemr. Tour Vaer rums arM temporary paaword will besent ed the email
addrmyme provicled al ava aRerthe information ce this form Is "Mad, This Form can be malled to
INS address or either of the fax n4mbera fined above.
Rece,ved Time .an.22. 4:32PM. �tdt- Ybf -P4ei