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HomeMy WebLinkAbout0969A (5) � __.�_.__..._. __._._._.,_... __._ . ....___.,__. _______.__ ._._._.. _ _ .--- ,_�.__ ..__ _. --- ------- � � i WpRKERS�MPENSAi1QN OE6L/�RAflON ��P�L-IGAT�:�1���O.R P�LU.1111.B1I�1�G.�PERAI�Ifi� i heraby atfiem�h4N i Mwve o cevnfka�n�of eoeRpny�p self � " �r�su.e,ar a�nt4�mu of 1Na9cee�'Gampenantlon Im�rrSnca. �AlEv.{n�e�l w o cerrtHed e�e rtiaravf�See.58C1(k1 td6:f.) COpN7'�'OF�.DS#�NG�L�S• SUILDlNG AND'Sr4F��( �y e1 ,py:,�� CamPA - ZI13:'� --. � ��R � -�e�tORY°Zf�.X1Yf �a -." .. . .: -_� -� faRAfPL7CiWt10FlUIN�VRtNtOTC�'OE� .. - ...�- �. .-_- �- ---�- - �-- � � Q t,s.w�p¢eoa��s chea wcin,tie biuirlA[nu msPee- � �' �- � '�� �-- tloedQ�trnlibtl,Y: . ER.'� ��i1REORt1EM fEE t� - - � --- '� Oat� _ /+pPlr I . � :'" � ' ._ F �.�NQ�p ��RI�RS' «� 1A�8 f ,, -.� �ow�R ' ` (Thl��r�en fi.��xat tii,eo�npt �d`ff�F.work��lvarwd 4y n�t / u�w[e �, .... P'CeB;e}� O� $4. ��. � tlis�p�F1�.1r;�6ro��hundt�d�Gm{�1AOhorlsn.l � urn�^ nDoa�ss t ce[t�y IFr7�o}th�Aerfa�,iiance ai�tw�rwo�4 f�wKxA�ho ... - . - r pemnit is q�dad,f[I�111 nnl�eenP�aY 0�9 p0eaan inany.ncnner �' �i+ "'� �� � ,'Ite � � �" k� �o m rc�bemmntntilaer��cM+e Warken'Campen�tbn 4pw.+. � - -- -- � � / Ot51twI�SMER � coWip/t[rOR � Dat!- �Pk711�N —_ _ —. —— cWTF1�SwASMER �. .- �� •.. • - .. . r ,�oncE ro neae�cn�n:v, ahef�wnq mn�mnro�� 127$'S Ma o1iA Ay'e. ' mptlltn. Yqn lh9I��Q b�AC4m� �vt�fl W Afq KLOrkers' SM�lMIWMG�4Cy Rk](EPTOc C � _:Mpensonanaaarronsat�het,atx�t�ade�r�m+uFrq��n- �r�itsrsrenn °tR3versi,de 92543 '�"°371.-500.0 . � wuh comDlg vei�6 avcb p�o+risiaw-or tKls Permi�-�tioq be � SxaR , ... - . - deemfld renFked � waiER�aTF¢ (p �NO. � LTC,�NSE➢�GONTI#ACTORSOEC44RAilQN ' _..D��+N6: -� � .R�9v � rdnrab�caE►tr�na�pr�amuc4oead+m�lsrpcav�si��atekwvre�v e�u.arsr�, cxrnps �.• I� (camme�d �wub^�p�cn f�o£9ianWn 3-oE+1n+Bus�ness p�ov¢ �- . . �. r ond#�e7a�Lbdd�Crd my IleetRe�in fu14 feres.andafhc�. S.KR�SY� � FINA4 ' �� } � VAGDA'fION � ; � �oah �r .�c-$'� � ���N��.�--�K.C�A,,,�,.�._ o EINAt � � Comracwor .- - �-_ - ere��. . - BY � � v 4 � I am exempt�undsr6ec. . d � N 8.8P.C.4or tlds reason � 2 � Plpn��k fe9 i . oate: � vt�+MB:wOOEHnnYF�SSVIN6 iEE S� �, . k slynmo.e . . ` �T07A1 FEE �.�# � , :_ Q i c;.%�"� 4 Plan cheeic oWp�imn� � r, . . . .5 . W + � SINGIE FAMILV � { 110ME OWNER-6UIL4FR OEGIAR�171ON �� � ( ��ereby oRirm�hm hom e:ampr from rF�eCantra�or'clieense �d� � -----� - .. � . �( ° � � _i�G �, !v far�he followinp ramon(Snc�ion�{1.5,8uainess o�d , . �:�� , �-`YrofeaaionaCacle): Ci�y --Tl. �� " � 1 � ; ._ _: _ � � I,os owner ot the properry.wiN do the work and d+e �--� --- .- - - � 1 li C�: -n.^,. a�rnnurc is no�cmq»�led ar oflered iac wle(Seetwn , . 7044.9�sfnau ond�Prefe�om tade�. � � GOIVSTALCI�4H IENG�WG AGENC� � . - I hereby o�irm�hc�Maro is c conahunlar.leddFng agancy fx � - . �he psdarmonee ef��ihe wvh�fw whieh�h'e permif is issued . . � (Sec.3�47,Civ.C.y . _ � i� I.endpc's Npme � � �I �!l1�C!s I�fff0�7 . . . h edrMy dieW 1 YpYp,ro�B�his apptioCqCp ond•llplr thpl�hO �. �. , p�ve�.�fare�qt�rm a onree�.I�e ua�m piy+r�h a1k Cmnry '` � o�dinonces ond�StU[e Inm regp)pting Pli�mbing,oa�n� , aufkanse rsprea0uiotives o9�hfa Cou^ni M tiY��dr � �' abs��merror�ned tnoRenr far�mpen�vum�ses. 5�Ell�Y.�li�E:�'lA��C��'A�l�[Q$Y iA2$-C��A�� RCR B'S�• ' �� 1�l7f65 �, Sipnom.e nE Pa�mixee De�e - .. , . I � __ . _..._ _. __ _. . _.. . . _ _ _ . . _ _ - � � APPROVALS DATE I C(OR'SSIONAiVRE INSPECTOF'S NOTES - OWNEP,-6UILD�R DEClARL1TION UNDER SLAB WORK _Z _ I here6y oflirm ihar I am cxempi from ihc Controcror's ! ROUGH PLUM&NG • License Lav, for the foilowing re n (Section 703I.5, ' GASPIPING BuslnvssandFrolessiar.sCodeJ:F.nye��yorcouniywl�rch ��. GAS VENT - � requ�res o permu}o ronstruct aller,i;nprove.demofish, � or repair ony struc�ure, prior fo I1s issvoncc, olso re� I HO7 WA7ER HEATER � � � yuire3lhe app7icont(or such pe�mif fo lile o signed sfofe- PWM6ING FIX7URE5 � men}ihof Fe is I+censed pursuanf to Ihe provisions of fhc � GAS 1E5T � � ConlraUor's Licen;o Law(Chepfer 9(commencing wifh ' UTIIIN CO.NOTIFlED � $ecflon 7000)of Olvision 3 al fhc l3usiness cnd Prolcs- ., s�ons Coda)or�haf he Is exempt thcrelrom ond the basls �r �� (or fhe alleged exemplion. Any viololion o/Sccfion � FINAI Gnlor n a �ron( � ` 7031.5 by any opplimnf far a permil su6jects flm nppli- � tant to a civif penolfy cf not r„ore fhon/ivc fiundred ' � dollars(5500).: � INDUSTRIAL ' ' ' " �� � ❑I,as owner of rhe prope�y w�ll do ihe work,and � WASTE APPROVA� � � � Ihe SINCtVro is not iNended or effercd for sale. � _ (Set.70M,8usiness and Professions Codr. 7hc G ^ � . ' � � tor's Llcense Law does no�opply ro en owner ol prc�_,ry ' � . wfio bu7fds or improves Ihereon, and v+ho does such . . .. . work hlmself provided ffio�soch Improvemenfs ore nof � lnlended o�ollered lor sale.11,however,�hc burfding or �' . �� Improvement Is sold within onr ycor o!wmpievon,the I � � - owner6utfderw111 have the burden ol proving Iba�he d�d i , . nof buJld or Improve for Ihc pwpose ol salc.) ;, � • .I am exempt under Sec. � � , �h 6 8 P.C.for ihis rcason f I Dole i Owner INSPECTOR'S NOTES i