HomeMy WebLinkAbout0938A (5) ______._ __._.._ ..-- -_.. __,.....�._----_�._ _..,,__. __
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WORKERY COMPEFI4ATION OFCq4Rl�TK7r1 ��PPLIC��T���!�-5�1�.�LUIUIBfNG PERMlT �
h �harebY��m�hqt I hcre a ceHifieate of comeru�o»l4 �a,�yf� .
inswa or p cOAffirqtp oi Nfrnkers'Comppnactton Inafufence, �817(REV.10+81)
', orocsnti.djeB,,,mI!Py1�1; l5ez•QWD.1� C.� �,`��+j�`(,��,";LOS;I►flGECES $171LDiNGA1J+D'SAFETY
l Pofiry N6W'-���524��mfrGeY��� ���� • . . . _ .
� Cerflfled co.�t is hefRlbT furoiihed.
� �-�7�,.,_ tQRAPR�GANT�9fLLl11uliR1lyTQRfVPE1 Bu4A7NG - ,. -
�rtNbd copy��7fpd wlNf thb�N71y 4�tditrq�inippc• AODRE4$
� Npf�S�Qpp�Tfq6M. NUN�BEft fiK�7REQR11fN� Qf
� l0[ALxY
i oaro.,.�i'�f+�.APattcaecs, ;�r_�`--_- wnhttaasa
CfKi6rCATE OF'EXF�ONF1�Q7V4 v�tl71CREflS' eamnre ��T
I COMPEN$A'11Qk INSURANCB � � -pMrt�p �, .
(thtA��ttfoKapr�d aaf 6i1+FvmptiAd 1E�th��rlc lnvu�wd 6y
�! !h► srmlt h�eren�fiu�dn4 dolCbn:=1'00 er Ins.) iwy�npqx �
I f cD�ify IBpT in 6i6 PSf�O1te�N¢9�oE 1he�WDrk lor whieh thia . .
� permi�is ipped;17hp11+nCtem{$Oy 4c�ftpAispn in arry mvnner �' GT�' m
m m ro beanmetiu6jen w ths WrnEeK Gampen3qttDn lows. D���
9 Doie . . . n,•••ykan+ cWnvswas�rt �r--�,�` � .
�� NOTICE(O RPP[KXNT:If, qFi�mqRYep Ihk!GentPYcate af �� ��"0 �+ �
Exemp�ton. Tou�dFwutd�bemme snt�ea ra fiv�FVaken' ��°���°�OR h
Gwnpemof�ae�oviaic�m af�e tabo��ode,Ymi m�m fonh- uww svRn+KiFxsvs� c�rv AN�.� 'E`� 70
��. wi6�mnlptp wRh web Prcxoiom ar this p�tmit aM1all be _ STaiE yC.
deamnd nnvaked �w/S1[rt NFJctER t1�+5E N0.
I` U�S�D C.DNTRa�DRS OEG►ARAU�fY c,RssrsrEnn aur�ia �ncr�o. Bv
. �herobK4i►u�rn+fie�tlpr�uce�Od�undarwav ot�('y��"�Ws.a
(GOTDIRRACRfl.�AAR�.S�Cf30R�OE QIYJS�ffA�Of'�FIO o�Si/�lS/ . �
�: and Prof@7iloni{�d�eoSPrtqt Iiesens0-ii+n 1u11 fqatsand eHee. OF�NKL r VAUDATION v .
ou
i u����'�ld,�,`��' r,r.e�xiw�____ � �
1,,,.�,��.�,� fINAt OF�
� CcntraO�".iai��-.�-���...,��� Dafe,,,�{ yi.a�-=� BY V
O I am e:emp�under Sec, �
� N .
8:8P.C.fa this recwn �
� Plqn ch$tk fpe .
�,;
nare; vEUM61M11GPERMtt 4�SwNG rEE t -a CI ..�S F
� Stgnornse � � �'��'
. roratrr� I � • 1f50
� • Pbn check applirqn� � < � ,,:�.;)?
�� S,WGIE fAdIILY �',
HOME OWNER-HURDER CECLARATlQN Name ii i.C�r'Pi�
j I hereby affirm ehW t em e:nmW f�om MeC,onrrecwr'alRenx �
� Ww iar the foUowing reaaon�Sectinn 7D91.5.8uaines�ond .A��O°s
I Profesaiom Cydek Gry �el.Me.
� ❑
I,oa owner uf rhe propenlr,will do�he wah o�+d the
anucturo is noe'nMrnled or affereQ faa wle(Section �
i 704A,0usi�eaa cnd Profenioru GudO)• .
G CONSiRUCifON IENpING AGENCY �
� i hereby offirm�hat�hero ix a comtr�Mbn iendtrig ogency for -
�he performnern of tAe wark fm whieh tfiia permi+n iaa�sd
(5ec.9097,Eiv.C.J.
� �e�dere Name _ '
J� Lendet's�Qd�eu
i I cenMy thpt 1 Kpre re�1 tlnt CpPlimtYmt y��afote/hat Ihe , .
�. abore�mlosmotion ia ccvrpCt I qprop to c�pTp1Y�dth oltCauMy .
: ordinoncas c�r}6mis luws�eW Youny Pl�mhing,anB+�aReby �
ouMo�ze.apresereonva�af tltis Caunry�io a�irar up�u��he
G cbrne c�eii a�oPery#rn�naveruon au�Poin. �ErF.��(�k3F F����XPI.�[4At+RRY t$N�17At+E
` (?�ir��fA��� �:��
� SigiwMe of Permittee Oate
_ ---------_ �.- ---- --- -__ -- _. _ _ _ _ .T_�..
�,_;
' APPHOVALS DAiE� I.vSPECiOR'S SiGtdATU�E �NSPEGTOR'S NOTES O'v`JNER-BUILDER DECLARATION�
�
11NDER5lABWORK I hereby affirm iho�I am exompt from Ihc Conkac�ar's
j ROUGHMUMBING License Low for Ihe following rcason (Seulon 70J].5.
i GASFIPING Bu51ne55andProlvss/ons�o(le):AnyCi�yortountywhich
GAS VEN7 rQqulres o permif lo consfrucl,oller,Improve,demolish.
� HOT YIATER HEATER or repalr arty slructure, pNor lo!!s ls5uance, olso re�
qufres fhe opplicant(or such perml�lo INe a elgned sfale-
vIUMeWG FIxrUREs men!thol he fs!lcensedpursuanf to Ihe provfsions of thc
! GAS TEST Confrallor's Llc¢nso 1ow(Chopter 9(cammendng wifh
, UTIUiY CO.NOTIFIED Seelfan 7400)ol Divlslan J o/�be SusJnass and Prolex�
� _ � � slons Co6s)er ihot he ls exempt therefrom and Ihe bas�s
i c7 �o� ihe ollegvd exemplfon. Any vlolollon oI Secflan
� FINAL �(cr an _trortl � . 70715 by any applicanf lor a parmi�sub/ects fhc oppti-
, conl to a Nvlf penafty of no�more lhan five hundred
� , dol�ars($500).:
iNDU51RiAL []i,os owner of iho property wlil do�ha work,and
WASTE AFFROVAL the sirudpra Is no1 infended or offered for stlle.
( (Sec.70i�,8uslnsssondProfesatonsCode: TheConfron
� � � _ . /or's lkena�Low doas noY opp(y to an ownar of property
�, � � who bvllds or lmproves�hereon, ond who does zuch
. . _ work hlmsel!prov(d�d tha!svth ImprovemenYs ore no!
� fnfended or o(fe�ed for sale.If,however,1he 6ollding or
. lmprovemenf!s sold wlth7rt one yeor o!complefio�,the
. � - � � � � owner•bullderwtll have fAe 6urden ofprovfng fhat he did
i . not bulld ar Improve/ar the purpose o/sole.f
' 1 am exempt under Sec.
1 �
� � B&P.C,for}his reasan
�
Date
I Owner
INSPECTOR'S NOTES