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_ <br /> :. • <br /> O <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE V <br /> WORKERS COMPENSATION LAV�S. <br /> MINIMUM 24 HOUR ADVANCE NOTICE <br /> N <br /> REQUIRED FOR ,. <br /> SIGNED TITLE DATE (7) <br /> _ ■■■■■■■■■■■ne■■!■seep■e■�■■■■■■■■■oa■s■ <br /> iiiiiiiiiiii0�ii��iiii�i=�� i�■iii■i��l■iiii <br /> ■■■■■■■■■■E■■■i��■■■�■ a�a:� ■■■■■■■■■■■■■ <br /> '��■!�ClN "�1PeL■gl1!!lllitii" 11lJCli�Sil■l� ■■■■■. ■.■ <br /> N■�3�\l�l�lil:■■■llile!'M�!�■l�lCl!■■■�■■■■■■�■■■ <br /> ■■■e■earn►�■ee■ee�■M■■�aeNelW■■■■■■■.■■■■■■ <br /> �+I■IrIA�!�IfiN!■r+■NCS■ ■81l�lil�l[r!:lRJ■■■■■■■■■■■■■■ <br /> .■;�■e±�■n■aw■■e■■ea■ ■-le�■■■■■es■■■■■■■■■ <br /> ■e�N�l�i!�7Nl.��ill��N�e��iGlar�iia>f■■■■■■�■■■■�■■ <br /> ,PEPARTMENT US ONLY <br /> Application A- B, Area <br /> Z ... <br /> Grout Inspection By e 0 SPECIAL Well Permit <br /> Pump Inspection By .. 11 WAIVER Received <br /> - <br /> .. <br /> Soil Boring I §rction By, <br /> COMMENTS <br /> Received Cherk0 Amount Invoice# <br /> Codes, I"(0 B Cash Remitted ry E"uest 0 <br /> !-7I ®® �_ <br /> - <br /> - <br /> CHI)43,05 8101116 <br /> cr <br /> o <br /> .. LU <br /> .. <br /> L0 <br />