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HomeMy WebLinkAbout1495A (8)x -xc n -rh "ems-'rl:,ex.-dR.v.kw.:...Jwa,w f. ::u.e�+. dtw�s.: x...:.: uatr..-:::�. ,.AxH.a x -.,>a'. '"I} ti.�F''.'i„`v�".vY�•'.,�„is-F.w .uz��kd-4,.`rv'z "+sem"�k'F:��`m-fir cr'�'.,J�i'a�ea�nptr•.. x fJ"�e' £"c,•. �iSSm w.. 5,+. +�r� WORKERS'.CCiM-PEtt{SAfION DECf,FtRATION I hereby affirm w a_ Insure ora certt$cate of Workers Compensation Insura{tce, or ' $ 'cerI led cop thereof ($eq 39Q0,`Lab C. III Pgjlfy o�company�_na CE Bas (REv @/61) APPLiCATION AOR P RMIT E SEWER SEWAGE DISPOSAL C cer,lff d� 5#ereby furs shed - Ce,rtlf copy Is filed with 'the county building Inspection " ' ' -" COUNTY O, LOS N E E5 BUILDING AND SAFETY E A.. �?._�, ed Date 97Y67$Ej Appl cant �'x6ElIIleliLl .. FOR APPLICANT TO FILL 1N CONNECTION DATA C�ATE�';O.tEv``1'Z31'�FROM"W''RRIE'f12S - ..,,,,•.,. r, C`o?APN�'kYf6N {i�HJYIfi2AN«C.`Ea -" STATION DEPTH ADDRESS .._ - Zc•x. 41V@5i jThis section neE'a not, �ie Complete 1 f}re war krl v by ti18 ER' , - MANHOLE REFERENCE - s perm It Is for one hundred dollars ($100) or less) 7; ... .. LO LocnuTy [OWER NFAREST .• •-:_ �. .... .- TYPE OFCONNECTION IENGTH PROM. - - ,.v n 1,c ert fy that in'the performance °Of the wor(C fqr wh�th this _. CR05,55r 1- Y CURB P1. :. MA Tq P} e it 13 issued I shall not employ any person inany manner Compenspilon is 'y - .. - - ' PCINo '- t;b aSElOS beTCOme subjectPio the Workers' S 7 5f 4 �� sM LDafe £ .. ,.SOB OWNER - CO IMP NOAN MAIL ''rL�n a n TRUNK PERMIT NO ROAD PERMIT NO.; _ Box 2 r. A I Cant ' PP cL� "- NOTICE 70 F(PPLfCAfi]T If after malc'Ing this CertlflCdte of ADDRESS .G© _L"" -. AFFIDAVIT WAIVER 'EASEMENT �i W'1T1Y3+£3 TEL.NO $J$9E?? i _ RECORD INSTR NO. DATE you should ico e to the othkwith gbor CITY LEGAL f t e colder- you must for..,, T ens ion rovfsions of ens P P Y n I wrh such ravlslons o/161s ermttshall be deemed I y P P DESCRIPnoN L - � . WIDENING . .. .. .. LL STATE EONCR.; BLOCK TRACT OACHMENT , PERMIT N6 �z, �.� ,« ? LII.EiVSf'D Ca«IS�L70 SDC ATIC� J - , - NO OF LOT - __-.. „�._..� �....,>.. $ ZE OF LO T NOW ON LOT o-+ �..., �,-�P' � I hereby of lrm fha�f:am license under proviSlons ot.Chopter �_•,' _ USE GF. q �} > ... Sinb9 P'g� 9 (COmmencI with Section, 7000) of Division 3 of the BUS! _ ness i'nd Profess�ns, cde and my license is in full forte and BUILDINGS CHARGES --1��ii��pppp���.{ - - •^ '- n. e{feCi - �.LT�yyyy:.�� qq��[n�r�n(� CONTRACTOR S A,y�F•Atb..1V SJ©1Y kR A CONNECTION CHARGE FEE Q r /�, r/f LICenSe er T `4$87 LC CIOS3+� M µ REIMBURSEMENT FEE pA "�.�• ,Wry~ yvDm ADDRESS D$TRICT NO: GROUP _ - MAP"' - PROCESSED BY -- V Cront OCtb„�PTBai Date CITY -iEL NO STATE - CIC Ll Om ezem t under Sec of the L.A.o , P LICENSE, NO CLASS (134 > Pfumli ng Code and/or sec ofthe NO DESCRIPTION OF WORK EEE .... nNAt o DATE VALID ION following 1 p J� CONNECTING TCk 17 oo HOUSPUBLE SEWERSEWER / - " B 8 P Code forihe reason x E' ` T P - R PITS' OR DRANFIELD O - BY® Z OUSE SEWER'CONNECTING PRIVATE DISPOSAL SYSTEM ®� gnafUre -. CSW1VCf�BUII'DER�EjCLARryA BLDG. O -- .. ..._ _ ........... WORK TO HOUADMON4SE SEWER R I hereby affirm 1fia1 I:' -am exempt{ram the ContraCior s,LfcetlSeP WERFLOW.9EEPAG PIT, pRA1NFIELD EXTN , CESSPOOL DRYWELL, MANHOLE 'tow for the following reason (Sefton 7031.5,, Bulsness apd Pro -.ALTER, ry� REPAIR OR ABANDON HOUSE -td 9, 5n., „ "5 Ons Code)' -SEWER OR DISPOSAL $YS?EM ,,,.Y MV I, as owner of tie property, of my employees with wages as their"solp, Compensation will do the work and tjTe sjrucfure„ 2 . , s not ntended,or offered for sale�(Sectlan ja44, 8ysmess- _ 7 !'-'� b rJ C) Rermlt 3 10 50 olid. Pr-ofesmons"Code) OWNER'S property, ❑ I as ownerofthe p p rty, am exclusive) contractingwith _ 7• C?AUTHORIZASON TOTAL FW 27150 llfen5ed Contractors to const Uctthe Project (Section 7044, Prgfess Code) 1 HAVE AT THIS DATE ACONTRACT WITH THE, HEREIN NAMED QNTRAC_TOq TO _ 4 CONNECT THE ABOVE' DESCRIBED EXIST DWELtMG: Yd THE POB"IC,SEv3'E1t""'"':`' fj�2g`56 " Business and ons tgCON5 RtlCii�'N`r`LEtMO AG NCY ". « -"`^"' hereby affirm Ihot there !s a' cons$uc6 fending 6gency' for the performance of the work for which this permit Is p P - SIGNED TNI$ OQNG bF )9 �±.,` OWNER OR AGiNT - - Issued (Sec. -3Q Cry C.). OWNERS L1A�'va�S A''" D ADDRESS Lende s Name x Seab'' Lender s Add ess ��.. .... - cerii.y Kat I have read `th`s dpp)icat on.. an slate i�iat the , bbo a informal on- s correct I agree to comply with all County Ch pod SfQC#p,lq>yg regulal ng Plumbing and 'Sewers, ITereby' aLithorize representatives of this County to enter ,upon the above mentioned property for inspection purposes - - G -4- ST t 5 gnat of Permittee Date - fEE7CE6'ERSEkrSk"E7Z;pTANA`TORY LLCNOVAGE - IN5PIerOerS wOrESn � fF�IVEIt 1Bi7ILID ii C � i.A,R:tlTi(J1V '. APPROVALS DATE' INSPECTOR'S $IGN.ATURE .:. •:.-.. ..... _.. _. I hereby affirm that I am eget-"t fromthe Contractor's NEW HOUSE SEWER . -. '. - License Law for the following reason (Section 7031.5, .. . , .. :.:.. Business and Aafessions Code) Any'eity or county CONNECT ADDITIONAL BUILDING OR WORN -- - - whirb requires a retit to Construct,.. alter, improve, S( P ` _ SEPTIC TANK. SEEP, PIT(S) - - -" . ,x , - :. strt �arJOr'to,it3 demorequire rthe a y " AND/OR DRAINFIELD . - ... -. ... "_ . jbr s tofileC a akarequires the applicant jar such permit to file a applicant CESSPOOL ❑ DRYWELL ❑ - �• , _.- - ' ,-:. _ signed statement that he is licensed Pursuant to the _�^ _.. Provisions of the Contractors license Law (Chapter 9 - 5, ALTER, REPA'ISIR, SEWER OR ,.. - (commencing witdl Section 7000) of 1%balAPian .i. of the � MOON ECr PL DISCONNECT PLUG AND - �. - ; , � Business an'l Pro fissions Ceale) or that he is exempt j - - - ABANDON HOUSE SEWER - '. : `. ...., _.� therefrom and the haws far the alleged exemptions. Any : - -BAOCFILE'SEPTIO TANKS ''oiokWonofSection.7O3l.3byanyapplicantforapermid .'..... SEEP. PIT S -CESSPOOLS ❑ :. ,.:' . '. mbjeCts the applicant to a Civil penalty of not more than w ) Off` five hundred dollars (,4500).: .. ® P -astiTeowneroftlxe o ke SSI he tstructure i5 nnE-in4ende(lCte[lafoth6Hle. (Sec. 7044, Bitsi>ess'twid Professdoaas Code. tractors Lic¢nseLaspnoes root, apply to an o of r Property auto build's or improv¢s thereon, and who does such -u oris 6m elf provided that such improvements ar�ot'tntended or offered for sad¢.°If, however, the a - bu' ing or dmprovement is sold withdn case year of y�e ._ } cbmPletion, the the ba eftbuilder for nd9d . ., Ili IYix E'l proving that f16 nGbSifdd sappPOV& lore Pu"'! of sada.) r i I a n L I a exempt, 44der, sec. s 4 BQ P.C. 14W thU MMA t 1 Date WSPECTOR'S NOTES - n. 4Z-..��. a CR t