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W GENSFLAWDOCSN9TAPPLVTOANOWNEROFAPROPEHIYWHOBIJIL�oURiMPqOVESTHEREQ�,AkD ----- ----— � = YhiOCONTRACT5FOH5UCHPf{p�ECTSWITHACONTRACTOR(5)LIGENSf.DPUfiSUANTTOTHF.CONTRAG FEE � ~ �OHSIICENSELAWJ. QUANTITY DESCRIPTION •� Y f � 'I I AM EX,EMr'T UNDER 6EC.. ._____ __ 8.6 P.C.FOH THIS REASON Q � � � U � � -- ---- . ...._ -- --- '---- [C DATE OY�KER F Z '__-- ' -__--_' _- U � LICFNSED CONTRACTORS DECLAHATION W Y � �I. � 141LHEPYA�fIRlA UNDER PENALIY p�PffiJUHY THAT IAM LICENSED UI:UEH PFlOV�SIONS OF CHAPT[fl a 9�COMMENGIh(;WITHSEGiiUN1CW)OFDiVI510N30FTHCBUSINtSSAi��f'ROFESSIONSCO�E.ANU � � � `X MY LIC[NSE IS IN FU:L FOHCEAND LFF[CT. ? , 4� (��.{ ,f' m JC'e�f:�---• ., r . . � UCENSECe�LASS �` �� . 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WAHNING�FAILUfi[TO S'eCUHF V!(]fiKfflS'CAMPENSATION COV[PAGF IS UMAWFUL,AND SHAIL OE . � fiU9JECTANEMPLOY[l7TOCRIMIN�IPENt�LTI�SAND(:IVILFINESUPTOONEHUNDRF:DTH(iUSANU ENERGYPERMIT � ' � U04LARS�SiW,aUu),INAUDIIIONTOTHECOSTOFCOUVCNSATI()N,UA.V.ACESASPqOVIDEDFOf11N ..- -.....________ ,_ _`_ � SLCI'ION37UBOFTHELA[30FiCO0E.WTERE5LAN0�TTOR`1FY'S�LES. RETENTIONFEE: ____ �� '__ .....____"_"_"'__'_"__""_'___._..... . . .___"___ � O CONSTRUCTIONLENDINGAGENCY PRE-ALTfEE: __ _.__..__.. . _ ._ ____ __ __ � CC IHEREBYAFFIHIAUN[1CFiPENALiYU�PLiiJtli7VTHATTHEREISACQ\SiqUCTI04LENDINGAGENCV % n- FOflTFiE PERFOHIAANCE OF i HF YlOHK FOFl WI IICH THI51'EFMIT IS ISSUEU(SEG J081,CIV C). '-' - "'-""' ' ' - '--' ' --- --_ '_"_' E' Z yi W __- __ -______.. . ..__ __. - 4� � LENOERSNFM� _ -"' � . . __"_'""' ' -""' . 1_- LENI1Eft'SADDRE55__ _ .__._..__-_ ' __.__ ` y3 ¢ ICERTIFYfHA�IHAVEqEADT4iISAPPL!CA710YA4DSIAIEIHATTHE�30VEINF(1ilMAT1UY15COR!{ECI, TOTAL F�ES ' � ( � tE W IFGR�[TOCOMPLYWITHALLCITYANDCAUNT�OFUINA��:ftinNl)SfATC�IAWSRELATI�GT,06U1L01NG � `� � CONSfHUCTION,ANDHEFEBYAU1HOkICEFlfPIifS[NTAPVESOFTHISC�UN'IYII)('NII�HUf�OYTHC � AeOVE-MENTIONF[1 V'HOPERTV FOR INSPECfION VURVO.^,CS. z COMMENTS � p � y- - ---- --- -- -- � -f- --� � --- ---- - ---- � -- -- a m ---- ----- � PEFMITTEE NAME(PftINT) _ _ 3 -���5`� - -- - -- � ._ � ._. ,-- _ , � _ .--- - -- - ---- , -- ._ __. _ � 51 ATUREOFPEFMITTCL UATL � � = RECPT.N0._ PAID BY ___ VALIDATIO ~ WHITE-De artment Co YELLOW-Finance Co PINK-Assessor Cop,GOLDENROD-File Co GREEN-A licanfs Co P GY. PY� Y PY. 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