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HomeMy WebLinkAbout1500A (8)- T�. r,k. - - - WORKERS ._COMPENSATION DEC[gRA7lJ _ _; - I herebyaff rm Thatl have a certifwata o' Consent o self, - insure a- a cernf tate of Workers' 4ompensgt on Insurance or 7eA4'a@b , CE 80C(REV, aa"ceTrt f ed copy'(hereof (Sec 36Lab C.) ---rr e ell FOR PERMIT .APPLICATION- - flohcy N ^� Company r5"'Ei- # rl13,!'„ es C'�Lr - : - { S.ETIER -. SEWAGE DISPOSAL Cerhft� c s reby furm5hed _Cert fled copy s,flled wth the county building nspecnon �C"OUNT�OOO CtiS%r1�lYrREEtS ^ BCIILDINl"o'AND`SAFETY' deportment - '- pa e 8120186 Freeman MON ' max Applicant `I_FIr A, �p l`OC+Iv RKE, S FOR APPLICANT TQ CO, NNECTION DATA ..:. BwtowG � _. .... .. ..,,., .. . STATION DEPTH 4 '�� `PETIS. TfOf� ASL�lfFAWIE ..t , SxY 'll v»„ x.xeq d ,�1rws 1 .�,,..., , n a. ADDRESS � _ . . ER.. d not e tom ere the work nvo vedb the ' (pTft S 5ectiOn nee pl y LOCALITY - - - M4NHOCE REFEREfJCE LO LOWER (d j w ermit s fo one hundred dollars $100 or less - . y ,:. .,. �.. ten x+n..,.: A .: A. ...ss ,. I certify fhat in the parformance of"the work or whish this NEAREST .. cRp56 ST TYPE OF CONNECTION IENGTH FROM .' v CUR@,'„ PL Mt TDP:[: pB7mrt Is issued I shall not employ any person n any manner ' to become to the Workers Com Lows - -. - - P.c NO so as sub ect ensation - *.l P P S `,`C +.'.I �Y7A",�f._ t " * OWNER GO IMP. NO, JOB NO„, � NO.: - ,�RT a"� rc` a* - vR ate �.pphcant - A EMAIL 55 P G TRUNK PERMIT NO ROAD PERMIT - ie. m Nb`�ICE TO Af'P ICAt�i if,, after maks ng4t its 4`CQrtr ico4e of WAIVES EASEMENT RECORD INSTR N DATE .� �pt of yov should', become sublect to the Warkers' ary TECNq818/967-954id. LEGAL ,,AFFIDAVIT - _ npensat on provisions of the Labor code, you must forthwO DESCRIPTION \OTNO. ,mi. HWY OR ST, W DfNNG nply p with such av s ons o this permit shall be deemed reJOked BOCK-- TRACT STATE ENCROACHMENT - NO OF BLDGS - °ERMT NO. ..Y. I ITereby afflrmt}tdl a�NI1cRe SeOLI • ^, R", • " , a d under provisions of Chapter S2F OF:LOT NOW ON lOT Z_ 1 commencingw th"S9ctlon 7000) of Division 3 of the. BUST- USE OF- DD BUILDINGS Sing.LL�.F� w CHARGES' r'S§ss dnd Professlons,.Code and,my iicense Is In full force and - - '�"` etFect CONTRACTOR FRkIAP7 CONST, CONNECTION CHARGE FEE a 474887 C34 License Numbt'er Llc Clasy`�s^ 8225,',BeEt:�'1W6 ADDRESS q, Dr. REIMBURSEMENTFEGROUP ;. TeeHi Y1. Date $x/20/WV ' C~Ontraator pp''99 ,4. T©�d 1!-TEL.NG 714/980-4,429 NO. MAP PROCESSED BY ' CIT`Fby STATE LIC - BK PG Q I am exempt under Sec - of the L A Co ;, x < / - r Ser - ucgNservo -47411 8 ttass NO DESCRIPTION CSf WORK FE'€ , , .. - "' - . .... - Ptumbing Cooe and/or y of the ,y 'f 4 SVG 3°-yP4 to 4�y" ' - _ HOUSE SEWER ,CONNECTING TO (� PUBLICSEWER ®4 FlNAL DATE Ly VALIDATION G. N ` B & P Coae forthe followin TITlSOIn d 9 - DOYe SEPTICT NK, SEEPAGE PCT OR ' Y . • -PI`S AND/OR DRAINFIELD - TTI FINAL BY Z E CTtN -TTY _,^ NATE D SPO SAl'SYSTEM St nature 9 ODCONNEEWER ADDITIONAL BCOG, OR .. .' _ s- y rivLyk Lp- DDX�N - TO HOUSE SEWER ^' I hereby affirm that �'am exempt from the eontrad`or's License" _ESSPOOL SEEPAGE PIT, DRAINFIELD DRY WELL, MANHOLE h - v.[I YE - - - .. Low for the following reason (Secton 7031 5,. Suisn2ss od Pro -,PAIR bR T+6ANDOtJ HOOSE - ' ` CoaeJ R DISPOSAL SYSTE(V,aons asowneroftheproperty, ormyemhoyees with waas s VQR xr�will O doThe work andthe,stmgcture intended or offered for sale (Section 7044Bus ness and Profess ons Codej ER'S as owne of theproperty am exclusively contracting w th ATfON TOTAL ,EEE 2 O 0 O —86 Ilceneed CO mractors TO const(Uct the project (Seatian 7044, HAVE AT THIS DATE A CONTRACT W TH THE HEREIN NAMED'C TRACTOR TO - BUs mess and ProfesSions Code) CTfiON-LE'1151(NG _N CONNECT THE ABOVE:DESCRIBED EXISTING DWELLING TO THE PU UC SEWER,` - _ I hereby affirm t}rat. there Is a: construction lending agency SIGNED THIS DA OF al' 19 for the performance of The work far which this permm is " owNERSAGEN - sued (Sec.-V?7 Civ. C) - - ADDRESS ' Lenders Name 5 .;� - Axl ' -. ax „„ �, °$ L _d .,. Lende s Address ' I cerh that I Piave ead th s aPp ..�.:-,,�,. �..»_,.-,�.�. �Icatlon an s aie,1 at t e _ �... ,..u:... ....._...... ... .. .. .. - to comply with all County - format on Is correct i agree - - 'ordinances and State, lows..,. regulating Plumbing and Sewers, _ u , hereby authorize represenjatrves of this County Tohenter - `.0 upon theabove menf oned property fornspecTlon purposes C� g aturq of, Perm Wee Date tP1sPEcroxsPBATES OWNEIiBUILDERDECLALt9TION .< DATE 1NSPECfaR'S 5f91NIATURE, - ih@re efffim that i amexem tfffoni'the Coutractor's Law YAPPROVALS ..NEW ._, - .. ... License for the�fottoiving reason (,SBctMx 7031.3, HOUSE SEWER Business and Professions Coded Any city or county —, ,CONNECT ADDITIONAL "'^ .BUILDING OR WORK - which regniret a permit to compruM alter, improve,, SEPTIC TANK, SEEP, PITS) '- demob k,dr.repair any structtare pragr tO.it3 issaaance, ✓-.: AND/Olt DRAINFIELD - - 6IS0 rBQBLfr'¢S' shet TOY zYCb permit tD file 6 -, -. CFSSPOOI.❑ DRYWELL[] signed statement that he is; licensed paarsaana to the - �+ provisions of the Contmctora Licensery�L��a�w�� (Chap,tfer 9 ALTER, REPAIR, SEWER OR SEWAGE DISPOSAL SYSTEM - - . - - (mmmencing with .Section 7000) Of L/8'Lr.Fian 3 _ (Y til¢ - n` - DISCONNECT PLUG AND - " '. Business and Professions Code) or that he is esaempt _ - ABANDON HOUSE SEWER _.._. ... . -... .-. tberejrom and she :basfs for the alleged exemption. Any - BACKFILL SEPTIC TANK'❑ violab$"of.Section 7631.3 by any appiicastforapermit . ,.. SEEP, PIT 5) ❑ CESSPOOLS-�. .., - - , --.. snbfects the applicant to a civil p"dry, Of not more than five hundred dollarK ($500).. .. .. ., '� `.""7T L as the owner of the pr ws'�% do the work, and is not inten d far _ I _ - ^.. _ i.p,,.G' _j ti.,.T t _:;` the structure ed'oi6ffered sale (Sec Business and Professions Godo 7Zl' 2' ou- - - r a _ - ...: �>♦� Li7044 .. Lracto'r?s censedoer slot apply to an of of )Iio)ser"t wA;o hai7dac or improves tbeieon, and who does snsb aooa hams¢lf p that such improneiiaants C, .. "r' of or o f wfor sale. however, the t... �.. _... _ ..e__. ........._. .._ - ' „s �-✓ bJaBfdi9ig OY EDad 9°6067nent SS. sn wi$�hin Oa aB,y6Ar Of completion, the owner,"Mfer taaill bane the beardon proving that be dad not build or ' far the PUL Sale.) of 64 as K '4 .. .. •M f h '.' '71i � rn b I am pt under � Tom., i Jw. v S x_A,& P C. 4br this zeins®aa 3 55 q ateIDate- VL"'ti�,,,.s+r3ry tY' 3 .i•$1... �.r �S 'G' '„5 J.� 4 i