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HomeMy WebLinkAbout1166A (5) . � .WORKERS'COMPENSATION DECLARATION � � � � � � -� � ... vzmof�ovw a e� � `� � �^�', I hereby.4ffirm tha� I have a,.certifirote of consent to self . �b��p , -' . � �� �'� � - � inaure,ot a ceriifrctrte of Workers'Compenwiion insur nce,o� ...-. ce eoe ,�- � � �� � -��a y ��.� �..." .�... .- ......... . . . . a certified copy thereof(Sec.3800. b '.) . . ��! � + . . ..- . .� � ,�u � �, _ �y_ �A. PL)f TlON FOR PERMIT Policy No. .. . Compony _ r.w`�F ._ �/�]/�/+ ❑CertiFied copy is here6y tumished. ��-- .. � ... %'SG'•"R���•�E�����5��'�� � � � � ��� — ? -- �---.._.. �Cer+ified eo Is ffled with the count bu�id�n � �Ot�NfY OF'IOTA�lGEtE q;' � ,� BUII.DiT�iCs i41VD SAFETY PY Y 9 inapection de rlmmt: " �-�-.� .. :.-.. _.. �... = Date�npp4com_.�� 'F�DR AYPCICAI�'i r0 KILL IN CONNECTION DATA CERTIftCAiE OF EXEMPTION OM WOkKERS' � � � . COMPENSATIOk INSURANCE n�ooaess � � srariow'�$i,`DA DEPfM N�� (This sectian need`ro4 ba completed if the work involved by the ��A��TY MNNHpLE REFERENCE 2 g.r.C.�'�,p' � R permil is for one hundred dollars(EI00)or less.) IENGTH FROM NEAREST TYaE OF CONNEC110N I cerlify that in iha perfarmonce of the wo�k for which this �gpusT, Y. CURB P.l. M.L.TO P��� permii is issued,I shall nat employ any person in any manner � �r P.c.No- � so oa to 6etome sobjecl lo Ihe Workers'Compensation Lows. owNeR ��- ^ �, CD.iMP.NO. JOB NO. ��� ��G,'1 // ' � TRUNK PERM11 NO. ROAO PERMIT Np. Date Applicam . p��u /z�i rc� /� V O NOTICf TO APPLItAMF: M, after making t�tif Certificate Of ��TY i/� ��/(nr' TEL.ryp. 'J/�J^ �1.�6� AFFIDANT WAIy(R FASEMENT RECORO,1NSTR.NO. DATE Exemption, yo� should become subjec� ro the Workers' IEGAL Compensafion provisio»s of!he labor cade,you musf forthwith oEsccivnpa IOTNO. MWY.pit ST.WIDENING comply with such provisions or ihis permil sholi be deemed ffvOltBd. � BLOCK TRACT ST�1TE ENCROACHMENT LICENSED CONTRAGTORS DECLARATION rao.oF eio�s. v�Rmrt wo. SIZE OF t07 NOW ON LOi 1 herrby affirm that I am liceased under provisions bf Chapter 9(commencing with Section 7000)of Oivision 3 of the Busl- eutoirocs "�' � ankcEs ness and Professions Code,and my�icense is in full force pnd E�fE[t. royTqq�pp .��� � �' CONNECTION�HAItC�E FFE L�cense Numbe.�3&�2(3 �IC.��455 � � REIMBURSEMEM fiEE O . , n r !�F� 8� AWGE55 a Contracror.�:.c..a �w:�Siu S Daro G L `(.i /'�O rei.rao.1/ '(�j '��!d' oistaicr ra. c�touP ru.v ev V cm � �^�[ / BK PG Z ❑�om exempf under5ec. of the LA.Co. S�CCNs�No. �J J �D�I c qi ss �' � r NO. DESCRiPTION OP WORK FEE (, Plumbing Code ond/or Sec. of the FINAL uSESEWERCONNERINGTO DATE r. VALIDATION w a B.&P.Code for the following reason $Ep�C LANKRSEECAGE PiT OR FINAL �,A ? VITS AND/OR DRAINFIELD D01B MpUSESEWERCCNJNECTiNGTO BY 7/V�% 9RIVATE�ISPOSAf.SYSTEM $i9na}U/C CONNECT ADDIiIONAI BIDG.OR � OWNER-BUILDER DECLARATION 'M1'�RK.TDNOUSESEWER I hereby aHirm that�am e.empt from the Controctor's License �zi�uF��ss�voaGoe�vw[upMnN�i��rne Law for the following reason�SB[IOfI 7O31.S,BUiSriC45 a(1CI Pi0- Al7ER,REPAIR OR ABANDON Hq15E fBS51011E COdB�: SEWER DIS SVSTEM �1 1 �.6 A ❑I,os ownar of the properry,m my employees with wages as ^� �• � n_��A #�'� � � O their soie compensofion,wiil do ihe work and the atructure ' `T'�'fAc-�+ a'F' is not intended or offered for safe�Section 7044,Bus"+nesa Permit b DQ $t�i.c+��.sZ i� •� �J�,�� and Professions Code). OWNER'S tS` ❑1,as owner of the property,am exclusively mntracting with AUTHORIZATION TOTAL FEE J�!fl.O 1 +���5�l,Q�� licensed coniractors fo construct ihe project(Section 7044, i HAVE AT THIS DAIE A[ONTRACT WITH TME HEREIN NAMED CONTRFCjQR t0 �� ` Bu5111E55 and PlOfE55iOn5 CodC�. CONNECT THE A80VE�ESCRI,D E%ISTING OWEILING TO T'E P1IBLIC SEWER. O A - 1`p^ � , � v.o V V�1 CONSTRUCTION LENDING AGENCY � J A � b.,,�y�— 1 hereby affirm ihai ihere is a Conshu[tion lending ogenry SIGNEDTHIS -�OAY4��! `IG� � y�p�f��. for the performany� of the work for which this permii is �NEROR t� - � issued(Sec.3097f 1 C iY.C.�. //' OWNERSP�t a .'F 4'� CO `�T�'�� ���M w Lender's Name/ /DG<�P P{�� �r.�[` ��RE55 / /� Z��SZ��� Lender's Addresv2{9/f^�1��(�JP f� - I certify thaf I have'read this appl�mrio�d stme that the . above inforrriation is correct I qgree to comply with oll County ordinoncep7and State lews regutating Plombing and Sewers, and har. y puthori repre tatives this Couny to emar upon�ii afldve- n�' ne oper�y inspection purposes. .GGc�L - � rr� ��� ignalura of Pe�mitfee /� Da� SEE RFVERSE FOR E%PtANATORY IANGUAGE ���$��� � ���8 � . . . . � yen ZpZ Tpy� h' �j Gnt� � � i Qn O< 7� NF #1$ � � � 8 D' i.�'. �� �� "�'p O T� ��p � O ,.' 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