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CONTRACTOR NAME PHONB E-MAIL, ��� z a`" ;. O�C_ qc4� —��U��� �.`c1� �5�*;�v`t���v' ; � -,_ - � �i�s e e'm�va � <.��,�r-= c-�cc `' ►C.��:. C i.�1 STREET ADDRESS CITY, STAT�,Z,]� �+, i 8�� —i t S� ��v `' � �1%'1 ,� ',c% L - �`\��,� MAIL CERTIFICATE TO: (Please allow up to 10 business days for delivery): CO 'TACT NAMF „�., PHO:JE y.. _ �.�. E-MAIL __., , � ��.`� �r��°�7 E w��.�. L 4�-��_ c. .�.)C' ��`'�3� i ` C"�Ji�� -'—'� 'v���C�'�ict Y'1�i�c`�����K1:'I'J C ,C a^C� S I Rf:G;I'ADD GSS CI'I'Y, STATE,ZIP - �,`-FCs> ��x��;ry�tz�c•r .���iti, r� `�i C� � '� � �-} �"��;) � � LIST ALL BUILDING PERMITS ISSUED FOR PROJECT: PERMIT NUMBER DATE FINALED INSPECTOR SCOPE 1 w�' _`�C��i��� _ °�r--� t _._j c:`".�jC, _ �f}; 2 3 4 NOTE: Ylease attach a copy of BOTH SIDES of tihe signed inspection job card to this application. - OI'FICE USE ONLY- SPECIAL STIPULATIONS OR CONDITIONS: CHECKLIST: Copy of JoU Card Attached(both sides)? Permit signed off in system? No other pennits open or expired in system? Verification of payment for certification? 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