HomeMy WebLinkAbout1166A (5) . � .WORKERS'COMPENSATION DECLARATION � � � � � � -� �
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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��'�� � � � � ���
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�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 �
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❑�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
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