HomeMy WebLinkAboutGRIFFIN REALTY, BEN INTERNET ACCESS.TIF04/07/2009 16:45 6267548999 BEN GRIFFIN REALTY PAGE 01/01
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A C AWBA COUNTY
C O G P.O. Box 3B9
fi y BU DING SERVICES Fa Number (828) 465.8962 Newton office
V 's' ERMiTCENTER Fax Number (828 )322 -68]4 Htckoryoffice
,j 4 ry Office Phone Number (9281 465.8399
Contractor I formation for Internet access
If applicant holds multiple licenses, a separate application must be submitted for each license.
ALL FIELDS MUST BE COMPLETED OR THE APPLICATION WILL BE REJECTED
Company name as listed on state license: iQ, d),., _q; c
License holders name as listed n State License: _ b cvr� A r
(If different from Company nam ) (First Name) (M) (Last Name)
License Number: /
Add
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Lic. Expiration Date: I ;Z ^ 3 )— 0
E -mail address: V61, ra ", _
(E - mail adpresse§ will be used for notification)
Telephone: $ - `758 - 37 1
Fax Number: 8' - 7 4
Mobile Cell: $ g - 34)L - .7S y
Name(s) of any other qualifier liste on the license:
Name(s) of any other person that is authorized to sign for a permit with Catawba County:
U 1 of applicant: ( Date: / - '._//
By signing this application, you agree to ma t the security of the log -in name and password.
Password security will be the full re ponsibilit of the applicant.
The issuance of a log -in and passwc ird will allow a person to schedule Inspections for all projects they
are listed on as a contractor. Your Jser name and temporary password will be sent to the email
address you provided above after t ie information on this form is uerified. This form can be mailed to
the address or either of the fax nun ibers listed above.
12 /19 /2007