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HomeMy WebLinkAbout1405A (7) WORiiERS'C0�IPENSA,+O\CFf.L?:R�-TICN - � --76M4:4� � �- - g �'^ -g /� �!-c s " ,/� '�j! �q`� -R� � ��-�� ' � ��� - � � - Cc875ti2�801 � . �E�lS��Lm/�CVG��� B'1�P�L���.eJ'i 7 I��1'V � I hereb�� affirm :hat I hai�e a certif cate of ensznt to se:f eQ,�T�-r����.��•l�i��a�'�,��• � �U��.B�TG AN��.�„F��.E,i,Y BIVISI�N insure.cr a certificate o;l4'nrke s Compensahon Insuran.e,or . . . . . . . . � a cerr.fied cepy tliereof(Sec.3800,Lsb.CJ - - � - - - Yolicp�No. � Company—.— . FOR APPLICAf�TTO FIL�IN -� eu��o�va .'� . � _ ❑ . . -. � . . . ... RCLRE55 - . Certrfied cor}�is hirchr furn�siied. s3ao[rva !' ❑ � � xDOR.E55 �GCALITV CertifteL capy a£iled w�+h the cr,unty�build�ng inspectien �������',����-�— ��� LOCAL�TY NEnaEST depnrtment. - � -- . 4.-�'�s��) L' f).. .. eRc.,s sT.�� � D'd[C APjJIiCASI{ ItiEAREST �- DlSTR!<T NO. G O t'PE Eo Bv . CER"CI1IC�TEL' EXEAiP'ItJ� FRO�I a.LRKERS' �� ��� I �� � - �� p I� CO�:PEVSA7IC\IN�UR.4NCE AL, s R `o"'�Hc. ��_ ocx. . P /$J�� .,i�.,.�.n c s . �ocw� ",a- ��"o. 3a:c i A��a���j �; (Th:s secti�a need not �e rom�.eted i:the wcrk i aoi ed � �� �� ° �or s�- 1 �� E E�. ��or�o�r�oNs - � hy�Y;e Fe:nit :s fac or.e 4iurdreC dei�ars ;SIC^v)os tess) E � �S�� � ��' ---� v J`�-So — - -SiZE OF LOT �%Si NG BLD �'�id I . � [certify that�n the pec.o�nance of Yhe xork`o:�vhr 4 th's � "- permit is issued,I shalt not empio��an7 Pe.ser.in any rra -o'Nrv`-R � i G�� I� - - � ..,.x '\a"5_ rc+�c\�� r W so as to Uecome sub7ect to!he Norkers'Compe7sation z -s. Ma�L �1-� S � 6 -- - OCCUPANCY GROUP � i . � Date Appfican: � �naoRsss� 0 y�,�. e� �rYQ.A�i_ -- . - ' —� g,�''�., NOT'ICE i'O�1PPLICA4`I'�;f.�aft�er making this CeaiPicaic of .�e��v�`��y,�.� �.`�To��'7} (p 4 � 6CCUPANT LCAD � � _��� . Exemption, yuu shuuld 'oecome subjtct tc tUe R`orkers' . ----�"- i Compensation prci�isicns ef the La�ar Code,you mus[fortlx- �� � A??LICATIO\FOR� - tXIT HARDWARE: .vith comp4y ��;th such pro��isions or this perni:: s,a1F be _z�t�R��se � - ce-o�ocv insPecnox - � I deeined re oked. � ❑� �Jo JpeC.KnC±��il. ❑ i i.ICtinSEll COV�<ACTGRS DF:i.LA4ATiQV � occur�Hcr vaseecTfos P8n-�QBviC85 ❑ f I herebc aff:rm that I em h.;ens d u ^r pr� s oas o;Ch tsr � -snFeTr�Peex�r[� ,�sT�-ems�e�ioav� no oF Ez�rs � 9 (cummtecing m-i[h Seceinn�7000)of Diais on 3�offhe Eu,s;- " �� � ness and uro`essians Co��e,and m}�licensz is in fui'.force aad � �-�'� � ppRKirvG. � . zffect. - . . • aE,.o � I aeov oEo � License t�umbEr Lic.Class_ �6 � f� � - -� -- LiiAiTEC TI�iE USE Contractor Datz _ - - oa_.E � . - �..rE Gi am exemp: .`rom the;ice;:sing:y�.�iremeers as?am a. __ � licensed architect br a egiste:edeprnfessior.al zngineer :zs o � � � - - -snscroP's, actir,5 �n mc p�ofes>ional ranzc�t} iSeciion 7051, &us- - Ex�srinc a�n��, � - . - s�o�ies �- ns'� inessandProfessionsC�de). � - . . - .- p[;vp�pFPROJAL / /\'��\ � PRES�NT JSE OF BUILOING- i/����� I b�L� Lic.or Reg Vo Datc - _ .. ..�o= HCMr O'�iM1�:R-BlILDER DECiAR?FJQN . o c uinnw�s. . . -.. . . . or wu�o E—_--- .. . � G� /. ti�. T :iereby afCirot thzr I am eaempt from the Cont o's � � �. . - b e- ' . License Law for the folLc�+•ing reasor (Saction ;03:.�.Susi-� . — . - . }` . , J�'� � ReSS�Il�YLf,°.Sc1:lRG I�7CI?j. NO�PARKIN :... .. .. . _. . . . . _ . .. . . . p — . . � �G B Ci..'.�lv . � I, es cwner of ihe propec:y.w u do:ha w�c:k a:i�tne � _ � � . - stru�t.�re is noT�intendsd or of'.ered tor sale � cF�on � - � 'Q44 B�sioess a-�d Yrofesvions Cudej. - ovessn u.,F e�em�o�N � - � . e � °��.�v:= CONSTY2UCTLO�I LENllIRC.A�r.TdCY' I� . . -- . � i,j-.I -`��.� I heieby afFlrm-that ihere is a curstr4ction iendine u�encp � - � - � - � for ?h2 pzrfo.-mance op!hc u�ork `or���It h Cnis pe m.t is f� . - .. , � ,suzd iSec 3097,Civ C.) _ . �� ' Lendcr's Vame vrsoPosEo mwx o Lender`s 9u.i_.ess_ � — e�iznn-r Fee � � - . ... . .. . . . . I certify ihat I hae�c read this ap�2icatiur�and s:at:ihut ihe - / � � � - - abo�•e informacion is correct.;.asree io com_plp�wut ail Count_+ ��ssunrvcE�eE f� s"Z� ordinances and Sta[e ia�i�s relxt:ng in building const�uciion, To-ra�F=_e ��� S� � - and'nere autliorize represenTz[ives ef ct,:s Couety eu enter- u on t �co e- n�ioned pmpe:x��for m pection purposzs SEE RF:Y'ERSE�OR-EXPLA�'ATORS'L:\i,ti AGE �� i . ��-//�S' _, _ _ _ _ _ � nature of Per�}zixrec 33a±e - . . .. . . . . ... . � . . . .. ... fi _ _ . _ __.__ --_, ___ _._.,. ._ _. .�.�4,..�, �_:_ :_- ;. , .. .. , _ � _... _ _ -_ _ ____ _____— ------ ---__._ _� _.,.:. � ::�� >. , ----- .�. : -- �..�.,�-.�_,x__.�. 4.__:.: �.r �-_-_ ,:,: s �,_:, �-����s:,r � , ,:, ,,, u� �.;,�-;.; . - . : .. -`� � .�� .._ - 4 �-,-, e �tis ;t r.e��to at �r� -. etre »t�r i - , � iaFPROVAtS �-'. .n.�_.�.. NS�E OR'S -.:.-.� . _._.: _..: . . -"_" - . 4. . .. . . 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