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t PLIC.kZION _.l UI.'RCRO'JKJ ':-VK RLZROi7T. a PIP:W- 2LPAIR PES-' IT <br />'3ZS ?E.:?[: •-X?:5A:S 90 WAYS F:C.•t TEE A?PROV: y—. Do v02".�i2'.L ZV ;U `:HA--kD AR'LJ :. P£Rr.S7 <br />—_7R.1m .'L:_.Or-ST PSA:= r"AZR <br />coat ` YEZ.fi?SY1 2 0 9 4 61 - 6 3 3 7 <br />I ADDRE- 5 <br />j acos5 STREE- i <br />-x 1 OWER/ov-puToa j PliOX� i <br />j Ii1/n - A', - I <br />c -rz7uacfa <br />o . ELITE IV CONTRACTORS, INC. <br />m 3 209 462-6337 I <br />! cDNYRA� :.DDR S 2535 WIGWAM DRIVE U LIC : 66001 6 • <br />T . I ; — A, C, 1 0, HAZ I <br />"ca"' 046-008761 _± <br />C OTHER - <br />I <br />T <br />R I <br />- in lTi�I}rlf �}ttrftf ti7i it t}fifr <br />I[itt /rf•iaa•Yza tafl �fu <br />. T.i.VX ED II --Q EKXC>J S �K=yY/P-R <XrSLZ DATE US:' ZRZ.'�I..27?`f <br />{ <br />I <br />T• <br />---1 i1�';ftlitlf iIlilfillilHill fill fill IIIIH III[i 11111[[if III fiffill fill 11111111111[1111[1111111111If[1I111tlllitilll[111III� <br />. � I fiYFROVsTS APYRC1vcSs wSITS (EDF"'ON (SS n. . <br />I rax Rtvr�E;ts:iArCL•' Q Tom% _ _ _ . � " � <br />Ii1IIa111tiTI[II1IIilillll.il II1 [Illi ItfII—SII Ilillitlll III 1I1T1[[I[1llIilllll[II11111iilll[I 111111 i[lI[il[IIIIIIIti <br />a??LICANr — 7£RFORH AI.L vORX.X ACCC1tn1-11LT Sa=$ SAX JOhQUSX rJCaR'Z O?>L'cNCL;,, STATE LAYS.ZCC ZULZS a/0 29CUEA7IONS7 Oc l <br />SxN .IOAQUrX C--K3W Y -AMLIC HE L 3-'ZRVIC:S_ CLN O. LSCFafiSM AC'X'S S:GIIATIME C!MTIFXES THE FOI;11 . -X CrS:ET THAT r <br />,.5. YF.�:-Okt<At`C;- OF 2YE j'ORK %IHIQt TXXS 2 I%trr ZS I-IMIMD.. Z SrUL RCT ZKPLOY ANY P'3LSOX nt SUC9 A --Abb?M AS ZO aErOrtE. I . <br />."rc2 TO u;Jt: T`+"i'S COn v'LAVS OF C3._=.^AXIL. cat:XRACIU2'S H124r. OR Sfi8C0KrRACrXW- SIC--A-URE CESYS FSFS' T3E EOLLO7 rtzC- <br />LSR:S IFY TS:.: LAS. 7NE F'EA vCE OF ':RE WCZG. FOR UXXCIE HIS P�dQr IS :.SS:IE>. S L F1SPL4Y kr-Z' SVd.JECT � v <br />ORXLit S 1 <br />:usLK;ArzoX .Aw of CAL:i I � <br />' : iF'LICAt-T'S .S;GJdZVRi.. - <br />1=1 1EXIIIG I JRA-�'NA.TTON <br />T-rzdicate .the responsible party to be billed for additional PHS -£M staff rime expended beyond' <br />e mit payment coverage per cam k- If the party designated below is different tban the pe=r- <br />mi <br />.Z.XDplicant, e:.9- property owner, .e D ty must acknowledge this responsibility for the billing <br />�v Signata=e and�ddaatte below. <br />address` _ pimne number <br />AA A <br />S; gnature <br />Z Ii 23-0018 <br />