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HomeMy WebLinkAbout1521A �._,_. .,. _ �._ ., _ � _.. _ WORKI'RS'COMPENSATION DFC.ARAT�ON . . , . ,.,. . . ... . .. . .. ,.� .. . .� . -.,, .... •, .....�•. �� , - . � ..- � F�crcby ofe.rm u�ot 1 nnve C1 CP.R�IKOIP of mnsen� ic seli . � n5ure n•(]Cer�}ICale of WOfkerS�COmpCn50'on Insura�re,or �`ae:.0 , , ,,_,,, , ,, . . . LS ��P,,:��� n �'Sec.38(H) y(: C' '°f•;F k' E•� APPLl�AT�ON �OR PERNI�T� ao�:.�.:-�f' ��. Ftxnd , —...-----— - `7��-�I�' .;shed 5 SEWER - SEWAGE �ISPbSAL ('....,A, , ._.. � . „....«........n ... . r.._. .'::,-.:.'... ..- ',�:.<:.. ..... . _ �X.e��•i ea conv�s�lee wiir if�o coumy bu�a ng�����a�o� COUNTY AF ld5 7CNG'El��"""" '� BIIitDING/C'�Vt7 SAfETY - d�F:���,,,��,� _.. . _ . . _. , _ __,.� � ...._ ��,«:__8��0�$E��������,�._�r6Q�an __ FOR APPlICANT TO F0.L IM __ CONNECTION DATA CFRTIFICATE�OF EXEMPTION"FRbNf�tiORKfRS'� ��_ic;;.c . • h ' ' STArqN DEPTH WMPENSATION INSURAhCE � ao�aess a �d�� � l� � _, - 'Th,s seuion need no'b�complelcd if ire wo:k involve.d 6y rhe :�a�-�o=u[�°,�v:t `�;,��q _�..�-� DTA BAR permi'�s for one hw�dred doPars i$100''•cr Ir.sa' __' "--l-- --'-'rEo�:ow�:�m . � NihRtv" /' �+ hr' 1=\�:.�-V;)'!. 1 c�n:iy •nat ir•� �he per+ornn�ce cl '��r wnrk fo�\vFLCh •^IS :4::`iJ�� �4 � s�y.e�_ ' C.:�es r. •^ ' ' , ' ' •_-- --� —__ ..". . perm�r is.ss�ed, I ynoli not emuioy a•:y pmson��i any manner -- ,;, �.;; w<is to hecomr.suive<.�'o�he Wc•re•s Comoensa�ro^I.uws �;,��k ,��� (x� cp iwp.No. ioe"NO �" ��"�� i> .. . . . .. ..... -a,�aeccw.:rtvo co�.�-�e�a�:�.r. >"° _Po BO .�.32�----�— Dn�e-----Aioi�;o��-------- i�fl.s5 _ n _ F " - , . . �:,*c NOTICF TO APPLICANT� li, �citcr mck�ng �his Ce•hficatc uf ���y • /� r7 •r.�+.' ��.�i. _,_,.. ,..a, v.. u ,F:;^n�or�on. Voi, shou,d bct<o��e s��biccl io ihe Workers' {�irOV1118 tE�No �f�l�g.1=�.��,-- '_ '.._'_ ' __"__'—'_" . . 1 ,,.E ' �ipe�sr.twr orows�ons ct tFc Labor coae,vc�mus°or•n��.�r.r. �`:r. � ., . ..., ;, • � r5c:r:r,^,� _o-•.. . .�.rv..RST 'i^F�IV• ,rcply with SJCI1 nrovivnns c� lhis pemiu sn�;� 6e decn;ed � ��� �f�^/ A /CVOKec. .::f.<,____�'•__ �!1%`h .:�F EM1'il�nCn•A=11 i � L:CENSED CON?RACTORS�ECIARAT!O'N � "q;;r 3°cn '�kv-n: . ......,. y,•: - w,.n;:v_' --'-- - �I1CrP.by r«Ir�n'1�-`'-. '„'.' �.','.,•,;:,,.. ',','.,�IOnS U��rlPqte• IISF.Of _'-'--�—_��_ _ . .........„. 9(commenring v �.� ;•.,�. � �'., , ...,.�... 3 0+ �he B;.si- =�u:�es _.`.5'1Yl�s �e5. ___ __�'__ -:..ca� ness and P�ofessi:��:':�:�,r �.:r.d n�v-�cvnse�s i•�.iu!f torce an:i '""— rffrc� �r� n� mh,a�:'c�r FPE�I''•TA�T C.�NS."�—.-------- cc...er_::..cin`.�r.�e � Iicr.nseNu�ibe�`t1488i_'—l�c CIO55.___fe�f.4'—.— ADORE55 $'�`�_5 �PPCZ'1Wf16]d 1)T' ...__'.�. � "• '_' o ""... .__'—' .�, 2� 86 . . __r...-' —. ..""""'T"'— "—"" V co�,�•o��o;_Freeman Do:e_...—��'—— I �,Alta Loma. ,-.N:3�L9FsQ-4�2� �� Br P� o _1'um excr� urtier Sr.c__„____.__of;he L.A.Co `�"�t . P; �:.,�,:: �7_488-L--_=.�.��-- �:T- �.`cr;�:rrov`cr,v^.1'e -- 'L Q,� ':;=_ V ?!umb+ng Codc n�d�or Sr.c._______ of the —�-�-c��c.. . . . ....__. ..._.�. ...__ � . 21"8f� VALIDATION .y d B R F Code(or�ho to�lowino reaxo^___"—_— 'I~�''_':'••-_'_ _ �V� .._... ,_ . � ....: . ..... ...._._... .. ... .__... '___. .. .. _ . Da�e"_—____'._— . ..... . ... ' .. . ---___ . , ...�.. ..... � �J' � . ..; �' ,...:' ' =I J L.I �t , . ---' .............. . ... . . .... ..... � S•gna�ure--- . . ..•.•.... . . . '__.__—'_"" .. •.� ..,..._ ,. _._._. .. . .. . OWNER�3UILDFRDEC(ARAT1dN . .. :`'��-..;-::.':':':1,�.. , —. . ............_ .... .._.. r o o a o`i � _.._... !'�ierr.by af{inn�hci�nm rzemp�f.om��A Con'rc<tor's Licame ,:..� , ":' ..:. '_'. ....._...._ . ..._ ....' _ low fur thp iollowing reason�Secton 7031.5,Buisness and Pro- ' � � I .�,a`�(,;�� . .. .� . ,, .,. �� , . r.,.' -... �ons Corfe): �..- � . , . . ... ... .. ."' """' ""' . ._.. _...'_ _... . _._ . .. .._ L as ow^er of�ha property,or my employees wifh wages as �' ' �������� thni+sole co^•oensa�ion �vill do ihe work and t,he.sirucfure- � �s rc'•n•endc<!o•o*ie�ed for sale(Seciion 704d,Bus`iness � Permit 'rj� ���cJ�&� ��<i P�o+essic�s C:,dc. OWNER�S �• -,I os owner u!the proper�y,om ex:l�srve�y ron•rcchrg w•,tn AUTHOltIZATiON TflTi�1L FEE�— 2 ^� Lcensed contrar'o•s�n cons,rur'�ne pre;ec�($ec�ien 704A 1-,:trc<'': :':,:"=F,Q:�T4>rv a'V.'�F�.sa!•t n:,:•°.:'anTac"�..'r Busness and P.O(e531on5 Co<Je� �UV.F^'I.c:.:1.'.v::,=5.'k'PiC Ex SiIN;J:4E:l_\Y"O'�f�'�.PI:`Si�.E: CONSTRUC7�ON I.ENpING AG�NCY !1. � ,,�G � � h�renv ai`.�rm t��c.r •n�rr, is n co�slru<tio�: Icntlin�ogency 5'[�\F^?�"S_ d A�^F_'_ ' '— �o• •�c f>�rformonre o� t!ie 'work 'o� aih.rl: �Y•�= qrmr .s �:�••�:�`:: �'l��Yj�QQl�Y%('f"�_ P :.'�:Y,c,:.flN" .� '__._ �ssur.n;Se: 3Lw7.Cw C' �^ �� _-� ,ar.u-'` � � '-�-�3CrY�►"� '�— ��i?'�AC��' Lerder's Narne_. '____'_'--__._.—._,_ .. Lend�:i's Aatlress—_ .... ... . . ... ....... ............................................_.........._. .... ...,...._ ... . . ....._.,,. _............ .............. . ..... . . I ceraly IFer I h,�vr re^�i mis app��ra��un ond s�a�c tha! •ne.... ahovo;n4ormclw.^.�s correU 1 ogrce!o:omp�y wiiH o�l Cour�y ordmnncr.s and S:cte !aws rec7�v�imp �iurnn:nr oro Scwers, ond hereby ourhn•i<e reeresenta!�vex u+ iFi+Co�r�v•.^. Fntr,• �pen�r�eA abovo-merhone.d propc;'y�o�:nspec��or ourFnses 'l � V,j�,�.,,,,,�,;,,L. (r ^�--_yn� cy,Q(N-!!___' "_J �^l."_ '! _�__ S!t7n�Pern��•��r. Do�� SEE REVERSE FOR EXPLANATONY LANGUAGE s�Mw».ws,'.......�...:�.'w4...,:wYu... .,,•.�v:.:.'.'.�. .�... ,- .:�x..... .. .... ...'"' marr.v.r.u�awmoeo ' �. .,. . ,, . . ........... . , . �. .� ,�i .. ..,,�..� ..:".:.:;...�.e.u�L�.......�'�...::�.:.:...,.'.... ' ' �_., , _ : . . ... . � � � IFiSAECrOR'S NOTES �� �WNER-�rA7IL'fJ'L''l2 l.��i;?, . . ' hR!'s�`F�hi _...,... .a„ ... .. .... ..,�.,, �.,, , .. .. �q'�������� DqTE-1 �NS�RGIOR'S SIf.NAIURE_�'� , -�. , . --� -.- . . T hzreby afffra tfiat Y ase�PmpY fsoar:he:.en?rec±ur'x �ew+:cc:tt:��H:-a ..... � ' ,.� . .�.` .' "- . .. . .. License i,aw for the£o![owir,g reasoa,.S„ciirnr%03:.5. —f'�r "'-.'T ,_ "__-"_'.___'______"_____'__ BTlS3t18S5(dY�d°£�9jPSSYC�S Cd[jBI��f9 Yf.� .^.f �'OlRA. � i..' ./ _ '. ' _`_`_�'__�' '... C(iI�iNECi A�JO'�YJkAL � �T : — ,�. . .y . �S'' a�::oin�r•ee woar I � , tub.cb regudres a pervmit.ao cosut�act,arter,snaprou¢, �. •--- .^---'---- demol�sh>�.nr�:mepair any s8ruceur�,P,r"aor ab 62s dsswance. ' SGTIf.TAAK.SEEP.PITlS; — '"-'-.-_-'_____....__"'.'__"_"'_'_"' .__ IS AnD'OC IMr1M�:F.l7 ' ' i � dI4o raqwfYes'tb�e�applimnP far ssck pernsds w Jik a -- --------'— t�ssrco: ❑ ORYWEII L I '----- ------�'--;-�----->---•---..__ signed statenze9aa abat he es dia�sras¢d�arscar,i t:: cbe ----'--._ __1__...-'---...__.� . � niTex,cern.R.se�v.it ou rEiauisinvu of tbe Coatmctoc�Lice�ua�f.au:r'C.i•rstat 4 scivnce DISPCSA!SYSTEM j i -----"— — -- feommentinr weib Seeasos� 70001 a,f J'3:ui•;euv �n.�abe ^:SCONhF^•T FiVG/�NO —~_'—•r--'- --B ' "' ` Brui�c;s a�d.ProjessJons.CordeJ or thot he 4s aeena/ia aea.nxn�HOUSE SCWER �_.�------ — --'—�_--"'------ ---- �.�sbcrefrua��vrarA tbe gses for afie al7eged exe»apt6ou.Any ;. nr,cerr.tsc^nctaNKs `.,..�..,"v I .:,.......,.,� ' . ".----'--- .. . .., .. . ..... ....... ... .bjectsdis9a;�p.rersv: •��...� ,d:. � • ur�.vir�si❑ rFssvoois 7 1 ' ....:� : .��` 1.�� .t.rr+�; ,�� ❑ �fitJ7piiGlt 3f S£CiuGr.7! • �' ,�� �'W'• _ _ --- 50 I'.. �.: ' . .,�. ;••+`�+t�..��'1�t --.�..�.,v. . . . JAL[!Jl12�GTZL�31fs'G'//S fJ.)li�.: ' C t.a:xhe owner vf t�e pro�sFs�ey wili da ctEe arot&,aad � - � , 1���:'��� the atrucinrn is�ot rgtende¢or effeeed for sale. � �:Src. YG49. d�.�c:xess,�ud'Arr.�cssia^xi r.:�dei'�'F.`�=on- ' ' ' dsae8r,r'.s<,iie;€:r I,ae.r,:rsc�: �n«appdg•ev aaa oi �oj . - praper¢y tc:5r,Surkis nr ixprarx,r tbarro�.and w6ddoes . . ., sucE worXe 1�i:ns�y"praue�ed tbat svech smpsovemexitc � • are r.nt:a:'exlev ur uj'jar�d for so%.If,boweuer, tbe . .. �— ..... ......".._ .. .......�..• buidim,q rsi �.. v..i.::��.. :r .�lti't.•3ii;�•: owe yeas of , �___-' ---- -'-- , catnp/rttiom. •i� �.�....r•.....,.�� i��ii: �:u..a eb¢brtrd'en � �, . . . . . . . 'of Prnunr„'S$at Ao:ild w�i bxild ar smapvoue jor xba . ., . J147xiOSf s�9F4: _ —�� __�_.�.�����_�_ C.l �, � � , . • , ----�-------,,. ., . -„_..-.-----�-- . ,�I�G1 CXcank t:iP::les_.�Yck'......_....�....__...,.�. . . . -- . ._.Y._ $�I''.1..i0Y dh:5��it35t7YS_-----_.-..,._.....- _--_ ._ ...�' �?.t�-__._.._____•,_'___'_"__",._...._.__".� ,--..�, , ........ . .... . , .. . .. , �9Y.7Y�1.�_, _ _._., ___ , .._...�..�.��._.�.......�.....,.....�..,�.............�.. . . . , . lNSP£C'fOR'3#i0i�£ •-.. ... .. ._ . . . ...�.r_-�.-_._......._.."---'----�_._._� _..__._.__.---•" ,--_. . . . . . .. . .. . . .. . � „ � . . _r� .,. ... ,. ,r.,..:. ,.. .. �_ .,. .,... ..., , , ---.�-._..�_.�--_ -' --' -- ... .... ..... . . .... ........,... .w.,.....,,,R.nv7.h p .. ._ . . r.'.... . ..r...,...-.».v•�».:�e...�„......nw. .. ... .......... .. ..: � ....w..,...w.;,I,.,......_.,r...�..................._,.