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HomeMy WebLinkAbout1605A (9) - : r ^^r ""7 :`� x ,�� zz'� %;�'�,"r'_"�^ �'.'�.£t'°•` 3:'. 5"�"��-��.w�'gy�`` �s-���� . N' � e����' p�c„..��#;, k�p ''`u�. �'��''�z �"-�s+S�B=a*�*�:n+'.:z >,� %: Y1YORkERS COMPEf�SAT101�DECLARATiON �. . �,�� � � 3 ;yA ?' ^�k �i YS � �. I hereby affirm fhal�'1 hove�a�cert�tgte o�conSeM io se� .. .,„„. ;..,,.,.. _. . " rcsore or a ceHificate�of Workers'C9mp�rispf.ion lnsurance or �"b'��x°' � . .. �.".. .' .. � . , � _ , .�. � ,m.. „ _ _....... . .. . ..pcenfed��co �h�«o+ 5B� 3�«�,�q��., �, ��eoe�a£�B,B� .�, :. App�lCATION..FOR PERMIT � �-Policy�10� mpany � � • ��� . �s ;. . .. . . _. ._. . H �.�,� f� . " SEWER - S�WA�E DISPOSAL. � �Ce tif ed� �t�`6by fumished . . r1 . . .. .. .�.. � . . �e e artment. A ��c`ay,.nr;,RrQ ,t�lr3,rt yr M *q a 1'h` ry FOR APPLf AN OO Fill i1�! � COAND SAFETY Csrified copy is filed wrth ihe counry 6uild�ng inspethon 7;SA�GE�Ss g�� �N�' � ,.,., ._ � P � ..E.. � � ... . . . . _ . y� ��[��'j�$� Pp � , NNECTION DATA �CERTIFYLAT�OF En[MpPY���R4O�1��ELLIgS „ Bl.Il01NG CT �" � STATION DEpTH � ' x �''� C"'O"Mp�N��7i�1t�fi it�(St1RiSKICE ., . ncoRess G : �v �,. � � . N ;(This sec�on neec�nor l�e comp�lz�e�rf t�e wock invo(ved by ihe � � � �, nwNHotEReFERenrce � ����� , .�, � LOCALITV LOWER' '�e�in� s for one hundred dollars�f$10D)or less) � . - -. , .�w- ,-«--..� -�-w--=r ryae oFcoHNeCttclN�� '' � '�n��'sH�i�tSM, ''`��'� ' NEARE57� ..: ��T�..�g .. .a..,�.....r � ' ... .... z"s�s to becoe e sub Qerformanee of"the wqrk,'for whiih ihis, , cao6s st. � � - � � v. � cuae � v� M�*o v.0 �.� . "�t t not gmploy any person in any manner . �- . . � - "'" P:c Na '�', � �n I ct to the Workers Compensaf on Laws owNpa-� .�lj,� �� CO IMP.�NO.� JOB NO �%?aF � `S �4 q�•P ; ,twt�- y�,q. ' . � ���}}}^^^��� �p �] , . . . . .,_.._, . _ ..... . S ' ' '�� �* ��� �"`'�' �� •'"` X " ��RESS ���.k7�� ��ZS - �� TRUNKPERAAITNO , , ROADPERrNITNO� � Oate ' } Applicant . . _...._ _._..,..�.....��_..�.... "k N�7��C�Y�F�p�rIC�Q�17 if tlffeY�IYt kln iFJIs C�fYfl<OfE O� `V� . � AiFIDAVIT WAIVER GASE11iENT REGORD WSTR Nq:, DkTE ' � .e ' ��TY �.NP.714�96"7-954�. mpno�; you should becom� sub�ec�.:to the„Wprkers �A� � � .�.��-.. �+'�'n e)rsqYitln rov�sions pf the I.pbor code; ou mvst foithwtth oescei�rioN ioT No -� �� � � '� ..... �. �.,..��� 4� ....�'.:�.-�--'. p' p Y . .. . Hwv 6RST wioewNc . � . �: _�nply�with suth provs�ons or.�thrs permit shalf 6e,d@emBd „ ,., � `�" '��`- " ' _""'."'"""."".c""`�.", � - �- , ._.. . _.,.,...._ _�.__.,.>....._...... �E Ok6(� � � BIOCK " ' TRACf � STATE ENCROACHMENT � . ':'��'��v '�t�'N��e'�*o`��,��Yo�`��cC`,�R'A�rbi� . . �r�,uu���o�� PeuM�r No. _ . _ .t�,� .�,:a� ���. �,«.y.i _,,,,rorC�wno� � SIZEOFlOi NOWQNL�T ., f�e eby af��m ihat h�am IicQnse�vnc�er provis ons offCliapter � use oF�' � . . , . . ,_.. .� �a x .;_9 (commenc ng wUh Sect on 7000)of Div�sron 3 of ihe�,8us euuoiNcs $lEl s �,�$a � � - - cHna�es" :� -- ''�ssGrsb Professions Code and my license ts in full force and � - — �- � �• � � ' � e�feCt p �p�S ?y " *.�}� � CONTRACTOR � - CONNECTION CHARGE FEE }. � L cense Num6er 4.�4i�$( Lm C�ass �7F4 �.. � nDDRE@S- .. � .� � , „ �•« .•,••. . _.. _ ,...,...._ ._-.,.n ' �., ,y�,E 'I�.ynB���� $/2Q'$� �� 15T . OU MAP ` P SEDBY � �Coniracfor � 1 Date � . arv �,.`t&3� �Q17Irr'T�, , �t No � 4 �� . � .':, ,_...; . ,:,.�',,�.�..,�i � ��, ., ,.,��r .... u �; . ., ..- _ _,��- �,-».. . . _ � v. ..._.�. E ., . , .,-.-. Q 8$ _ p��g/�� D RICT NO� GR P ''. •. 'ROCES u `�' ❑I am exempt under Sec of the L A Co ucENs���o 1�.'Ta. .,r C�Ga u��eN , � tG 8K O � ���..,: '' Plumbing Code aad/or Set �� � �� of ihe No , DESCRIPFIbN 4F`VJORK F"e�" `�'"'"'. HNq� ::.. -�:� � � �- � � �V ` � � 'F'�'� a"u°g�,scsewEA'"�"NecriN�.o "."""" oare f,: VALIDAT ON y � � � 4 , .�.. , 7.7 C1� D /���'-� .. :- 0 8 P`.C�de for tFe following reason � .- , �Sea'�c r.sNK 5eevaGE p�r oa ' F�NAi ' --.-- - Z § G� .: "' d �' jk ; .,.z"� �. .: PRSANO/ORCIXAff�FlEIC �W � aY ; 'f" - 5 e ; DPte ��� :HOUSE S�NER CQNNECTING„TD"� " �. G% ��' /'�'� ^t � � � � .�`. . � PkIVAT OISPOSAL SVS7EM � - 4 SlgnalVre � % �CONNE AD41'jIONAL'BL�G O. •� ,•..• . . . ..... _ ........ .... . ...._.. .. <b,nr . •�' ` 'vVORK TO HOU$E SEWER .. �.. . .... � O�X/IVER B'C71L6ET�D�C�A�2A��St� `. : ;,�h, �ea� • .WERFLOW 5 EPAGE PIT DRAINFIELD I here�y�aff rm ihpf f bm exempt`from}he Contracto�s License'��� :Ex?N C645POOL�Rvwe1 nuNHOte - � �' ;� Lo for the fo�lowing-reuson(Secton 7031 5,�B��sness and Pro- � athe Reanut ott neaNCON FioUSe, ' . �- . � � � �i �;�;�,rj j}�.' . �. . ,,.'�*•IonS COCIE� � ' _, -SEVlEROR OISPOSAL SVSTEM .�. , . -. ,s.:. .,z �n ..._ �>.F . .,.,_ .; . � I asowne ofrhe.property oi�myemp(oyeesw�hwag�sas, - . � . - � � � � �- "` the sole com ensation will.do ihe wo[k'.pnd ihe siructure , �� ��� --��4.,...,���� . � � f4 is n'ot intended of,offered tor sale(Secfiqn J044,,8usines�""' �� � � �- � � m-°��(�`�'.� ' ..�� _and Professians Codej �- � �� �µ�� �� �OWNER'S� - �.d .Q ; Permrt $ _ ' ' ` " AU7HORIZATION '" ��i `u t�1� x ❑I as owner of Ihe property am exclusively contracting with . TOT01L FFE , `�7 �'}Q � � ' �� ..;; Lcens . .,, ._: . . . . , . mYQd controcTo.rs to co�srrucr rhe p[oject(Secrivn.:7'64d; . i Na,ve,nr Tr�s oq1E A coyTanc7lviTH,7He_HEREiN NAMEn coHiaaCroa ra �����„�6 - business dnd professions Code) � coNNECT rHe.neoV[p'ESCRi,aeo E%isnNG�,,,,�_�E�IiNG 76'�'#�fJei�G�E'�h'Ek", s �� � xu��,:,, CONS��l7�TIU��11E'h`fD��A�'a"EY��V "'.� . . y/ ^° b� . . . . � I hereby aNirm�ihot�here s a const uc�qn�ending ogency��� SIGNED'fHIS,.��_��DAYOF eY 19�. OWNER OR ��for ihe pe formance��,pf fhe work f,or,which +his perm t is owNeas nc�eNi- �"'�� � � � � - - i: issued(Sec 3097 Crv.C) . . . .. _ .._.. . ...,.. . .,,.... 'ta :� - -.nPoaESs . . . - . ��, �; .: ., _ .. .., . Lender s Nome � ,,,�,. : a � ^*2`a�¢�-s.r� �� � rd � < �...�'� -t°�° .��. ,�- �,} , `s ; t �. �F � �� .��r`d'�^"�:`��`'�`�.'��^t r"�����'k�u'�, ����r� �., s�-r�� �`� � �.ro � �.q 'q _ ,:. LandarsAddress a,�� - ,.�,a. .. ..� � � � - ,�..-,.--. _«...a, ................. .r ,..r. ,.. �- (ce�ti�'ihat I'have�read this�dpp�catron and,stafe that,the_, � � �� ��'�'� � � � � ., _ ..., ..� __..-..., a__.......,...,..,�_. . .: .__�_._c.., ._....___. ... �.._._ .,__.�_._._—__. __�. . _ _.. ,�: abo e nformat�an g co rect l.agree ia comply w th all County � - � -� , ;� ord nanc"es and State I`a�s regu(ating�Plumb ng onxi Sewers, � ' � � �, - - � � � � .�,....�..,,.._w. . ,?`�-,and heieliy aufFiorize rapresenidt ves of�tliis County'.to'"enler "'' ` .�:". '"" .`�.:. ".::,. ..."". .``. . �... .. .. . . . . . , Jpon the above mentioned proqerty for inspecfion puxposes � � . � � � �� �- - . , .. - � . . � . �. ,.,x .- .. � �e��nr►�tt,e.�rw►e?wv' c4z' �—S=9G -�. , Sign.atureo�rmi}Yee . . . �afa .,".-..'�" • '��.�-'• �„�•�,-" '"S`Et"kEfiERi'€�'d�tERWZiCKIAYi9RVLYcNII;UAG'E-. . . . - . . . : . . . � . .: , .. .. .: . . ;{ . ,. . .� .. . ., '[_' _ „ .. . . �.-�-: ,.:; r �.. .w s. , ._ . .. . „ .:. ,�,.:_ , . ;"` �r , 4„ �< <.r:.' r.,,� � �., � �- -�_ - ., ,.:,. . . . _. „��`�. ., i �..; --- - __ _ . _, - -_ __. _ _-- . ,. _ � �. �,Caf,2: ;,,s ,,.Y,,: . .�� AP�R@V�eLS-�. ._�����r w ccioz�ic ruae "��..��� -��w •"�•°.__;"�-`-+.�iN3PECT�RSNO4ES . _. ,,.� � ;� �� "g���a��rin�hae�ata��xc�sgtfrpmtTs .::,..�:: "� � � � ��� � ��.,� �.�e. ���S��TIQN , ; . � � _ . �. � . . �Coarracmr's , � : NEw t+ous�sewea ..:. . ... ...: . .. :��..r ;;a ,, r.;�:; a.�� ,:... < � . .. � .. . . LiceaSe Law fm•elte followim�reason 9S�zaiosc 703T.5� � � - .-.:_ . Bwzmess�nd��''srofesafoms�Codok Any ciey or county. . �� COtJf�EfT�ADDITiONAL �^�•. aunoiNeerewo�c .. . .. . -. ..:� ' � . �.-'. . . wlricl;�segs�sres ce.�ermrsr�sa�ronstsrect�ad8er,�ianprovs, '` sEvric rnNec.�s�r,aRts) :: • � ... . . .deennPish��s"ra,��yr o�y s,r�sc6eer�ej,��iqa�.'1,�:�tssuance, ; �' AND/OR DRAINFIFID . qyJsp ( �'" .. . . . _., ... -- . . . - � .. .reqsda�es tbe'a,�ip%icaria .smcb'. eranse.so f'rYe.a �' Q �:,.,c�ssvoa p ozrweei.❑ : ,.'�� �..:,.. _. .:' . : .:.� , ', �. ' ssgsied s&e�anaerit�Bhoe he.as..Pieevued prarsuraat.8n abe " rahre,eevaa.sEwea oe �,,,�. P�visimsxs of tbe�ConerrastoP's I.acense LaF�(Cba¢}�ter 9 f � ' �.;. s�vnc�oisrosn�svsreM .. .. . . .. � � .. . - ...�. (enmmeesci�g wsab Sertaon 7Df1d91 of�T.�viadon 3�of tbe �- qSLONNEGT PIUGAND�.� . - . � ' .'�� �-."-. �..�: . BT6.88S6@SS O47�PTO,�BSS10W3 P.Od�BJ�OY$F96$}�l¢9S¢9fQ8Dt�$ :�; ABANDON:HOU5ESEWEk..� , '�:... . .:. _^.^ .. . ._.:__"; PIJSf'BfR9HeldAO"4IlB.L38'SS,f.53'.`�J¢�E�i2g8.�I&Y8i78�PtOR.AfYj! �'+ az.cocFnysevne rAraKs❑ ; '.. srioJasioa o,SecBeoox 703Y:5 b a �- s�Er cirls ❑ cessvoots p seb�ecPs�e appTic�¢aas so a es 1��Tty»jaa�vm��e� �„._; r :.. -.LL (^'z�..�� ;�:,-�'� �� - �ve bsxdred dolPat's�'$36Q1>r , ��. { _❑I,as the mwnee ef fl�e p ePdil do thewark,�nd _�. ;_ _ �. ; , �,- e , �_ :,� �, � x ,t �� �":��°�' 1'� �L� #he stcaetvs°�is aiot�ntended or offered#ar sake: ; . � ,.+ (Sec. 7044 Bruis�e,s,s,�+end Professaosis�oile Tif-"�'-an- ` � � � � sac�rem k Amrase yraooded.tbae strscb �� ... ,. , :3k� r�C� . ,. ; � .y k . � : � _ plYOfiEYiy 3DdlD�Paf�S�w a99l�bTOVBs t�IBT8091r ll9Ma wdlO[lo¢S ` , . __., .... �,e s - . . . �_._,. .„�.. „_....._ .,, .. _. . ._.. .�: '� - ' 1V/ . . : �.� g 89qf11'0;18 89iL4 �..�'. ; , �. .._ r � . � are�io8 iiidevarled��or afferart,gor sale.�,a�howav�ew, abe _ _ _ ;� ;�ssi5; ;nx�f� . , ,_, d,tiarldirig or ffxprou@ew°.ea�sr.sol�auitdkra nts�year af �..._.. �Y. _. ' '. '�,. �� `� �.��., — - .. ._ � coe s$e burden. �. ` ' L � J`^ s�,,a,; rovs Yha� e��SwaGd�or�'�rove for tb¢ a- : - � �a� � .m �.. t,ti�,. . ; _ Psr�osa of sale.e`b�t 'h.^.',:^1, ; s�.��, .�: .-. . .��, . .. . �.� a '. �Y��t7'.Yr o �. :. • ,_, .<..- :� 9 - -� � �..: { . " --, , . . .,:a �.5 a-Tq i'_t�..:1..C," •_._�.�.�� ..C�� °.:�`$HA�S�jSL Yll'I�1'"�" ,..H . . - ._ ,, : .' � . . ""a '���., j ..5 ; °�; .'-r '��'t . �"YE€�''�+.E��_ B��c��'.�(➢f#d11S SQ3SOh : .„„ ,� - . I �- - ,,, ..- ._ . �._ . �. -- . . , aix � n � � � � �` � � � :�.. . . n4`f:.W ka t h ,�;�` .. ,. _ _ . . , , .. . .::.+ . � . ,:.»... � � ,". � . � `�g���.a�`'�`�"�v �. 1�StE ...._ .. . ._._... _� , � ' , � - ` % - - ' - � � � - � f)Wil@�' ,i, -. .. ,�.._ ..- - ,.... ._,,... .. .�.�. ,.., �.�.._. �... ,.. ... .... .. �. .. .. �>.., .,.. . , .,. .., :..::......__.:�_ , . ,:: _.�. .�..: , . . .. .: .. . . ..,. ,;' �NSPECT6AR'S NOTES , _ �.___ �._., ._._ � . , __. _._.. .. ' a : y' . : �� ��;,G.,.�.;�.;.�::� `' �.,.�z.v a�. ,.. . . � � _ ._...a.��_ ..�. .:�:�..�. - . , �.,�.�,��.�,a,,.. .. _: " - �� .� . „ � . � ' r� 4 ynl. "_ � .}ye- w^S� TrtYb d a'w.�s�.r. s �.c�..�w1s uw. r�.�, S•+ n.t� taa�.�v�.u�.:-..: aY s�� 9'� �.eFk:K.e. L��. i t:. ,:. a � ;� ,r, n, �r ' �... � w«, .. ^�s��^ � , �,.� � ��.���,..,, � .,,.,��.s�[..�,;�.,.. , # v �f3"x 4�t _ s A a"`-' ,. � .p ., .� _ :a. r�r»,: . ��a4 .i���� �.����YrJ`��'.a���s �` 1 � P ., ,.� � �: . .. . ,. ..- " _ ,�; �,.s.�,�-���Y�C. �, < i�,.��.,��. -».��. - ".u....,a,m�i,;a� �.�,.a����.,c�:.��..�'�:%..�.�us»..a,,.�, �, .... . , . :,: . .�.. .,- .;. ... . ;. .,„.. - „ ;.. .. . . -` .. . ... . . . _ . . . ���...�._.��. 'I. . . �..� . �.��.._.. .,e.....� ,�� ,-.F.�s�.�,«,.+a;...�,.,.�,M:.�.-�.���ra.�..,��h��,�,�,:,� :��a, 4 t �__,g � _`'y . . .. ,... _9..1 r. . _' .b .lr.d:a- ....a.,�.�,t�?u �-� � � . _ .�`.