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HomeMy WebLinkAbout1500A- T.. r,k. - WORKERS I herebyoff rm that I have a certificate' Of consent self ,to ' Insure a� a cernf tate of Workers' 4ompenscgtidn Insurance, or ieA4'a@b e��t f ed copy thereof (5e� 36 Lab C. CES�tREV8/81) APPLICATION. PEf�AAiT -FOR - Pohcy N ^� Company C'�LA -: - { SEriER -. SEWAE D1SPOSAt Cerhft� c s reby furnished _�Certfled copy s filed w th the county bulldmg inspection '-COUNTY LO A1�6�EE�5 BCIILDINOAND'SAFETY' department - '- pa e 8120186 FreeMan TO Applicant �C+Iv C(?il Fl�ts'A'F pl`ORKE,S FOR APPLICANT FILL IN GO, NNECT1D 6N ATA BwlOwc- ..:. � _. .... .. ..,,., ... STATION DEPTH b PE'NSdTtOfS INtCYR+A* Cj� 4k bn r, ..Seok ,TnY .tet ,; wsoir .�,,..., ..a a.. leref`the ADDRESS . . ER- mp t; work nvol'vedb the Th s section need°`not e tom p y LOCALITY - MANHOLE REFERENCE LO - - LOWER, u ( eprti s h ane hundred dollars $100 or less - NEAREST - ' - - .." y TYPE OF CONNECTION a�.,. r., ......:,. I certify that In the performance of"the work or whlS.h 1f113 cRpss ST am VA."'T.OI v - CUREt PL ML TDP.[: - pE7mrt Is issued I shall not employ any person n any manner t0 becom Object to the Workers' Compensation Lows.OWNER -. - _ ,'.. - -c N o �}'y 50 a9 CO.MP NO, 'CE'No,- MAIL - NO.: Yate.pphcant - ADDRESS .: _. TRUNK PERMIT NO ROAD PERMIT - J29 ie. , ,';; +« ... .;�. NO`fICE TO Af'P�ICAt�i lf„• after makingItis 4`CQrtificote of -" AFFIDAVIT WAIVEII EASEMENT RECORD INSTR NO. DATE bion y P should become subject Yto fhe Workers' ary 7EC NO ..�jj LES - - _ _ - PTION - n p forthwith Lath 9 enply sath DESCRI �CTNO. Q.i. HWY. OR Sr WIDENING such p av 9 OnShO perm t S q I befdeemed revoked BOCK TRACT - STATE ENCROACHMENT : x ,.�, kt!. tltf nSE�"0 CiSNTRACYO�S'�E�L ,.,, „ ,. OF BI.DGB - PERMIT NO. ,y, pro`.'I.. F- . .,-::-..,•.e.z> .,.,.. _. I hereby affirm that I am ficensed under provsrons of Capter ` 42EOF:LOT NOW ON.IOT ii` commencing w th,Secnon 7000) of Division 3 of the. Susi- USE Sing. w BUILDINGS g CHARGES '' r'S§ss dhd Professlons,.Code and,my ilcense is In full force and - - '�"` effect CONTRACTOR FRCONST, C CONNECTION CHARGE FEE a 414887 C34 License Number LIG CIa33 , �SEqEMAN hayy� 8`G *q[�e(?'.4kiW©Q��� § ADDRESS -S2, REIMBURSEMENT FEE 6 �}„��t e� ,/asp (' } irTe CHif ?3. Date Vii GD/ WV Oontractor p'9 ,E, (] Al u.�' L©�a' 714/980-4429 DISTRICT NO. GROUP M,AP PROCESSED'By' l! hr .a4,:: ,? R Y +b '"V'."'*sTS. t3"�+ ,` CN TEL.NO STR7E LIC PG � 6 I am exempt under Sec : of the L :A Co ;, x < / - 't ` Ser - LI LICENSE NO, 7 88 - CLASS C 4 NO DESCRIP7101`FCSf WORK FE'€ , , .. - - -�-.. - Ptumbing CO R, and/or y of the ,y 'f 4 SHG 3°-yP4 Ea 4�y" - _ - HOUSE SEWER ,CONNECTING TO PUBLICSEWER FINAL DATE -d -- LU VALIDATION G. y B & P. Coae fo the following reason a s Date SEPTICT NK, SEE➢AGE PtT OR ' -PI`S AND/OR DRAINFIELD - i5 FINAL BY Z - .,- G HOUSE SEWER CONNECTING T., PR VATS Df5POSAl'SYSTEM Signature -W DD�� �� s- y rivL qP'B CONNECT ADD1710NAL BLDG OR -.WORK TO HOUSE SEWER - ® p " hereby affirm that �'am exempt from theOnifOC70f°$ License _ .OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN. CESSPOOL DRYWELL, MANHOLE h - v.[I Yt - - - - -'Pro-,..,, Low for the following reason (SeCTOn 7031 5,. BUisness and ALTfR, REPAIR OR AE.ANDON HOUSE - n'�i"':ions"�o�e,".. •. ._ .': :SEWER OR DISPOSAL SYSTEM ' f I asowner of the property, or my employees with wages - -27.50' 'f ;thel[„sol wmpenSiDtlOn,. will do the work anti the,stmgrture . -i_ ns not mtended, or offered for sale (Section 7044, BUsmess, : x. - and Profess ons Codej: OWNER'S Permit S s " ` 215.o ❑ I, as owne of the property, am exdustvely contracting with AUTHORIZATIONI TOTAL -EEE- 27,50 Q G - €j p Ilcensed CO ntractors TO COnS T(Uct the project (Sectioh 7044, HAVE AT THIS DATE A CONTRACT W TH THE HEREIN NAMED ;C TO - BVS mess and PTOfe3SIOn3 Code) -' �ON'STCTi"ONt LEDI(VG d�ENC' #- _NTRACTOR CONNECT THE ABOVE_DESCRIBED EXISTING DWELUNG TO THE PUBLIt'SEWER,` _ .. mo- I hereby affirm 4} at. there Is a: construct on lend ng -agency 1 SIGNED THIS DA for the performance of The work for which this permit Is' " owNERSAGEN - sued (Sec 3097 C v. C) - - ADDRESS Lender s Name 35- .i;E 7aa. I cath that I Piave ead th s appl catlon'a fsae fat fhe'»- -above Infprmat on Is correct i agree to comply with all County - - Oedn ODLe5 a�d35tpte, TOWS re - gulating Plumbing and Sewers, and hereby authorize representatives of this County to enter - - - - - - `-' upon the above menf oned property fo nspecTlon purposes Slgnatureof, Perm iMee Date '?61:�T��S�`YAR"EX{fCdYJdT`Olti'�L'7iNY.6XGE.