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APPLICkTION ?C2 UN-DERCR0UK.) C;--rK R;-TROe i _ . Ot , _, _.+G -U-PAIR PERnIT <br />73Z$ 7ERK:: ZX3:RES 90 DAYS FYcN T} APPROV;,_ yt-. DO v0T tIzm " A SHAD,Z ARZAS. IvJ:U:E PEFr.IT —PE L-'IA�f: <br />PrPiNc YLTRIR <br />A SrT`- _ ;'RO.-FcT CON AC t TELE?scN< ` 209 4 6 "i -6337 <br />j- ILz:Y = �2�- r�_ ©_' YY�a�vY\ _ �"°'E. 20c,- 33-z <br />! atoss srRss- <br />-T<, G c <br />I t <br />z ! OuNER/oP_�uroa ! Paotr : <br />-�O c! � '�3 - 3y 16 i <br />c `O,nyACT02 �'"£ ELITE IV CONTRACT O S, INC:. 3 209 462-6337 � <br />o' <br />1 corlRAczcIR ;-ODR£SS 2535 WIGWAM DRIVE U I_IC = 66001 6' <br />r i—_ _ 1 _ _ ! — A, C, 1 0, RAZ 1 <br />R ! I,nt>R£R `S\IV- c� 046-008761 + <br />A?- — - <br />C j OMP IrF'oz AT=Ot+ 1 <br />T I <br />o! . <br />R ! AxoNE z 1 <br />7.L�tX iD S t T��_, SZZE CL-FKICALS STORiD CTIRRF1rMY/PRLVROUSL7 DATE UST INSTALLED <br />1 11 <br />- - llilt 1I11IIIff1111HIT 1ytI III III III111 fittIII111101I11111111111111I1IIfI11IEIIl1tIlIIIiIIIlIlttllIiilltlIlllttlllilIlIttlltlli <br />a 1 <br />1 _� //"MOVED APPAG�vEI� .+ITiF IO�II)z-=_fit tsi:,AP-;ROVED I <br />--1111�31t9IiIt[Illltitll U Itllltttllf,Ilfllliittttlit.11111lllillilElI11I!ifll:4IIIIIiIHill [III ttflltrtiiltlt113tTtilIII1IYI11ti <br />t <br />?R.It,;74t7 rfV' : 7£RFORM ALL vOAX =M ACCCRD,.vC=" '-i-Tf SAx JOgQUIN CY70U'Y STATE LAWS, \24D .2i7LZS .lND 7FYT1CA7ZOtii Oc <br />="a.V JOA(; -rN C'OClWrY' 2USLZC HEAL:'3 _` ZRVXr S. C!:Na4 OR LSC10SM AG.T.4-5 SiG-,!ATJRE CE <br />RTIFIES THE FOjZ",YNG_ -X CM -r_" THAT :,Zc t <br />-.i Px:iFGlUCAI:C OF' 74r uORK FO? %tHICH TBX� iS LSi7ED- I SffiL NCI EMPLOY ANY PERSON XTP -=%-A KIJINEA AS TO BECOME, ! <br />S:191ECT To "O(: %---;t•S COMPEXSATI0.1; LAWS OF e-Z.L_=CAXTA.- C0trZRAC7UR'S uj;'ntG OR !MBCONIAAC_T11= SIGRA--WZ CEnXFZES TRE FOLIdrII.27:1 <br />llRilEY 'L •i::: I?I T)TE FEAFORIti.vCE OF '.H8 WCZ': FOR uHXCEI TIIIS Pr2gr IS ISSUED. I SHALL EMPLOY P-RSONS -=JECT To u0PjX L -S I <br />:_;IMpm"ATXON -&V5 OF C ;FoRxXI._ <br />Jf' <br />C� Q - ill\ <br />;.LICAC-T'S S:G7a'ZVRz', �. TLT1.F. <br />li_ ILLING INF'()Jr TAT1("4. <br />=ndicate the responsible party to be billed for additional PHS -Eta staff time expended beyond <br />r�e:mit <br />payment: coverage per tanTc_ Zf the party designated below is different than the permit <br />acpplicant, e -g_ property owner, zhe party must acknowledge this responsibility for the biding <br />�v signatu=e and date below. <br />Ne^Ej'� �t I U CoacfOf address3S phone number <br />S grlature . T <br />j <br />-c--ii 23-a B <br />