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1506A (8)
� : : , � ,.-� � ..� . ��--� i �` +� WORKERS'GOMPENSATfON DECLI�RATION ,,', � � � - � - - � � �_ �nsure��oi a�ce�r�t fica e of Wotkers Com��ensation Insura'to self "- . . �� ' � : . y ..� .� , � . -� Ydtitia2o, ,._ .._ . . ...., , , . �. rt�,. . . ..__ . ._ , ... - p nce,Or .. � � ' �+"'�erhfied co ihereof�$ec 3d06 Lob C j� -� ce atla'(kev,eiei7 , - � - ; Po,,<Y�ro �o,�Pa�Y �t� ��a �, APPLI��OTION FOR I�ERII�IT � ��� �EWER��= SE4HAGE DISPOSAL ��Cervfi c � ereby furn�sh�d �� � ; ���Certified copy is filed with the county build ng inspection COU�TY OF LOS�4NCa�E$ , B'JRDING 1�ND S14FETY , ,. �'w.!a;+,i depa tmant , _. .. , �. . . � � -: � : : . . `��Date 8 '�� �i npplimnt F3'�2IqA13 FOR APPtfCANT TO FIIL IN GONNECTION D1�7A` , s`"� .�`,3�`•CE"'R71'�flG 7��OF a.. ^y :�y � ', i x,: � . . __...._. � I �MP���RU �� ERS . ; � BUILDIfK " STATION PEP'iH . r„ � .�� / « ..� _>.._ � . '�-2 P Y 1 � . . yy ' . .. ���`'��h s se"ci on peed,not'�e cam lete i t�� A�oREsS �� _ � �„�CSMP�ntS�`�,`,�frb�5 fi�ISd A .. ; . p � or�c involved'tiy the. .•' ' .-. . . r,wNHo�eReFeaen�ce . �P ea ..,,y . . LOCALITV � � �L WER g p"�tmi7 is�for one hu.�..d ec{�ollars($100)or less 1 . � . ,. - . ,.,.., _, •,,:_. y -..»er .�..,..a•.-. �-��. . ,.: .... NEAREST • .• ' •�. '. .• ,..:�. '�TVGEOFCONNEGT7PN IENGiH FRO+k� ��i certify.'that in t�i� Per#ormQnce�f the Work�9r.wnich ihis ..... caosss'r - �. � � l ' �v. � � cuae�' a.i nn�ro v.� � ; p�'im�l s issoed I shali not employ any person�n any manner : ��� - -- � � .� - v uo �/��.o�. � " ''s'�as tobecome subect to the Workers Com ensation Laws � p�7 y�� ry�7� � � -�� � I P OWNER .�.1Y�J:tiY � CO.IMP.N0. �JQBNO '� lTi1,L ' ' �+ � _.��4 ��. ,p�� '����� �„�„��.�'�4�{%�y,}�S"�ti"` �TM, '� ,. MqIL� � .- h � TRUNKPERMITNO . . ..ROADPERMITNO . . . ... � a �012 �1()P�1COn1 ADDRE55 ���'��. ., 4 �'`�- ._ .. .... . :; ,„,:..,.. �.. '� " " �' qFFI�AVIi WAIVER EASEMENT RECOR�.INSTR.NO. DATE . � NO�fCE JCS�A�P�IC�ANT`�f ofter maliing this Certi�ica�e of citv�� ��$y�,�y,^i3,� iEt Np ' - �� � •<r�mpi�o`n yo� should become�subjeci to 9he W,orkers' ��A� � �' _ � � npensatron'provisions�af the�Labor code,:you must forihwnh oESceianoN „������o'rNO. ��� ���� �����-�� � nply with suth provision3-or�.this pe[mii shqif be deemed . HWY.�Ok57.1M1PEN�NG ' £�s dE"IO�Ced q, . BL�CK. -.� TRACT '. STATE ENCROAC�iMENT �- -- �"��fi ��� t�'C�NSE6C�b AC'fOR5��bE'C4�f211TlO�l ��� ,�-,�r �. .... .' NOOK'BibGS � vERnnrcNo_ �. _. .. .. .. � , .�,,:,,+ .rc.rs2..rM ._ �.. , , SREOFLO� NOWON_LOT :,�.J he e�y�af�irm ihat-I am�fcense�under prov sions oi Chopter usebF ` ' " ���"'" ` � ,. �,9(cammencing wi�Fi Section 7000)of Divi;ion 3 of the Busl- eWL61NG5 �1ffi e �G$s � � � cHneces' '�' '��' ` ��' � . ''�'ti"e'ss'$`nd Professions Code Qnd�my Laenge�js,n foll fo�te and .,_. -� � � � - - - '`e�fec� � " - � CO�.TRACiOR . " WNNECTION CHARGE FEE- �� �� . .O}.. � � ,.,. � r � > �, ��. x ��-x,?."�' ,�� '_ L�CCnse�UR1bG1 �O I.IC C�O55 f,L„J qpp 5 8 � � REIMBURSEME T FEF . � � , RFS '� ' ' �''"a��+�"-�'� � $'�' F�� � � ", � �� I KICT¢IO GROUP� MAP GROCESSED BY � � �s�o hactor �TPPiR9a�1 Date�$�j_ � cirv..-,�µ,'�`�1, �y(}}pj$ rEi Np . � � F„✓ ' =. ' D Si - 'n z .�3 T r.�. .�" # � rj�r�u I am exemP��rvder SecTof rhe�A C� ; % uceNse No oE���'�a�qR� �ciAss � � . ..-... �. � 5 BK F �., ,a.e , Plum�mgCodednr�/orSec �: � oft�e NQ�� �. NOFW , �" . FiNA� � �- � � - . .w �;¢y, � - ' � N' �:,;x � NOUSE SEWER COtJrIECTING TO DATE. �B`;J�� � .VALIDATION a � �i. �Y ' �� " � t � . �' g �Y�0�6 foI'ir�B�O��OW fIJ I6a60f1 Pl1BL1C5�4V�R'� - y .. : i . x_ � .SEPTIC TANK SEEPACrE PIT ON'�; �� . � - � t �, � � f` � PITS AND/OR DRAINFIELD FINP.I� . ;, _„„� : � . DOP2:�� z ' .HQ45ESEWEh�COWNECI�G70 •� BY . . q. �� : '" � �, �',�� � .� � `� � �PR Yfl7E 615Pd5Al SYSTE ' � pSignafure � � � CONNECTal7dlT0'NALBTDG OR ' """ �` "." � . -� �- �� " Ol�t}1�f2 B�1`IL15EFf b�"C'C�RA'�Y"�bN � � woekro Kouse sEra�e .a:w;..- - s'sAb . OVERFLOW 5€EaAGE PIT,ORAINFIEID � .�.� 3 {',�"�„��L'+:H - d •,t her�by�affirm thaf I am exempi�'rom f�ie-�ontracio�'S�Y c"ense' ` � �� Fse7ri,cEssrbo�,oRrweit.�rn.aNnae � � - � - � � �� Law for(he following reason:'(Secton 703�1'.5',Buisness and Pro- � aiiea iiev7`ia-0z AEaNOONHOuse .`"' ' - � � ... . '" �a ons Code) .. . �.. _ ;.,., -. sewea oa oisvosa�srsreM. . ... .. .� . .� . � ��t:� s��.� T (s � . . . > � I as.: . , �«,.,,, �. a ,.,>_ .,..., - .�.,.. � : � . ._ . . . . ': �ov✓ne of the prape�ty,or my employees w�th Evages as „ �_ , , . � �.o C'];�O � �� ihev sole compensat on w II do the woik and the strudure, � � � � - ' �� � � � is nof nfended o�r offered fOr safe(Section>oa4,aus��Ess � OWNER�$ P��m�t �. �. �� - � � � 4' �1��.������. . . . �� and�,Pro{ession`s,,,,ode� ..»>.... ,.... . . - . � . . , _, .; �, w /CU7F10RIZA��ON ��ON1L PE� , 5 �I,as:owner of the properfy,-am exdusroely contra41ip9 wifh � . ��� � u b,��9"'�i b..J � IICEfISE(�COflflOC1OR t0 COf1StfVC�.lflB PfO�0C1(SECf 011�O4E, �� I yqVE AT THIS OATE A GON1RRCi WITN TH�`FEREIN NAMEb COtJ1RACTQR?O, . � . . Business and P ofess�ong�O�B� CONNECJ"hE A86VE OESC@I�ED EXI$TING D �YdEll7NG„TO�Tfi�M33L7�'SE6VER - � � Y . Sah x 'F't ,.: .. . - .� . � � corss;r�uc�raN��;r.mrntc dc€Ncr � � � ., I here6y affvrti ih6t t�ere�is�a constr"uE�on lending;pgency� Si�NEorHiS ���o',/aY 0 � iv_�., _ . . �v 5`for t e rformance of ihe work for which this ermn is °`�ER oR ��� �.+ - � .,R, CB P. OWNERSAGCi"T .� IYVY��/LC'�'�V'� � � ..reaissue�(Sec 3097 C v C j .. .. - '. . ;'°f `'w�: a t ; ' ��. s.... , ADDRE55 . .. .. . . i x C�nders,Name � . ' . � �s . � -'z� �r�:, � �pL�r:. � �,:-� � e-p' .;�p'"'"'t�+.��u.�"'�"��`�"��""��i�' a�'���f° ��a'��'��.�>'�` >#� -,ut��C"�"� `� ��'� M��"�'�'e^3fi a"�„:a � �.� ;' .. " Lenders'Addres3 ` - � ,r,... . . .�.�.� , , .�. >.,,, , � „ ,:e.,� ,. ,_,: . ,�.m ... , ,.,: �,F=a'�"I,cert��f..,that 1�have rea�e_a licat on ancY state tfiat ihe -� .� ,� .,,• �". . . , � .' ��' , ��. ����� �� ..� � '..,. ��: �, �,_ . �_ ,. _ . � 5 Y PP .-. . . ` . .�. .. ..:� . ', - �above i,nformat,on��,s comed I,qgree fo comply w ih a1:4�County � . - � �� " �- � � � �� - ,�,��'ordinances and�Stat_� laws�[egulating Plumbing and Sewers, -� � '�� ��� �"� - � �� - �� � � -� � - � &nd Fereby aut�iorrce repre�enidTives of 15 s CountyT�enrer _ - � _ -' � � _ -� � ,��`'��po�fhe above-menfioned properfy for inspechon purposes. . � � � � , ' �'► c'�'f`�-��$',� I .; Signature o P����� Date . _ � A7�YI�X" .• .. ... � .... '., .. SE�REO�S�'"pOR-ES�p2AN l7�'NG"YlACE x ... � .' ": '.�. > :I :.: : : i - ,fl...a.i.. _ _ _ __ __ - � � . , � � �. � _ � �t �.',� � �. � ���= � v3.. �f��:� •y rYrvMi';g�,`"�' �T�y � `�..,�1 � �'«� i£.�����0��7� _ 09'Y1�IJGR dJ6JIIL�Y:.141/S. ... . . ��=���.:� .�h��?� �� ��� ,,.�.�-�-�u ,. , -�OI� ssicndiu � _ : :-, ,�.. , , ,.,,_ . ; A��RO!l�aES oAre " iiasvEcroR• ' � �her�b�affirat ehaa i ana exe�pt4rmson the Conttactor'� New wous�sEwex Lfcemse Law fur tlne�oltawS�ig;eesaae lSacttos�7+D3�.5, .. -, . . . '�-�... ` .:'�- ..,.. ..:.'.;�.. , ..':;°; . . .` �.:' . �,...,,��Business awd�Profea.sdows L'od��Aaoy-�.oity Ur c�kianty .. . �:�- LO`1NECf ADDITIONRL . . ... , .. � YpIJ CS a ¢S51SiE$i1 COffiS�°4ZFCE� Apg��ifYP OlJB�� .; BUIIDiNGOR�NORK � . . _ -.: , . -�. . . . _ . . YC 4@!�'Lt! �5 - $J' � �C . . "' .' �".- '.. b. � ,' t� .. , . . ,. .• - . '� •!• �,,. �^__ � tB�l�M;TB�d'3T��SfTkCdSLA�r�+7$01"�d,,3/,�4&¢SYNbAt6� SEP?ICTANK-SEEP%7(5) � �8���� � `� AND/OR DRAINFIELD - - . . - " � RISO iPeS tpre XYc6RR. mP SBt�F} , � ' mba8 Fie ds ea joerNiat Lo.fi7e a� ` . .. : se �statevneset � f - ��cEssi�oo�,p..,.onvwEq[�', ' . �. ",. ' 8n .Paear7.cmd�prcrsuaa�d ao s4ne �__ . � . ..� ���� ' - -.� -� � ooviseozas �z5e Co�aBracdor§ „ :,:.. � . .' �� - p . of . . Y.,isesa.se.�aw(Cbap&er 9 �,�' -.AL7ER,REPAIR.SEWER OR . :.� - . ` . .. . � IC01119)iEfiSlAvO'9U83�..SC68YOA3 7aOCI}O,f.�IY/3SY0:8�o,�8ID¢ SEWAGE DISP03h15Y57FM. ' :,. . ": ' � . ' . . . � � . DISCONNECT PLUG AIVD .. . :� . , ' - HYISSeAf.s.4'R9ta�PfO�P.SSieMS' (.�ad¢J afi$Jlat,�8.iS¢JC69eiQffi ne�vooN wouse sEwea �., , tberejroena reaed She�.bcsrs for eF�e aUege�'�x�enptrovs.�ny anexFiu serrie rnwKs[7 . . � .. �. ' violatEo�arf Ssstcoss 7031.5 6y'aee9+s27pdfc�ant$ora�erarsat sffo vir s�p cEssvoo�s O ~^ ° sbe ap.plicarat to a stivi8pesealty a¢serae more xbka � �`a'��'''U :�: �. ��^���..L3� � �. .�'e-Se.e,b xdred dol�srs!$50��.: .�.. �ce "�:�s x ,` :: :�` ''� CJ I,as t�e owa�e of the pres@�ap wi11 du t�e woslx,�nd � ^ ' u �,G�s`.-� �,�W:� �: , `v j the sPaeictaze ia aot'sntendcvi oe offered foz sale: � � *� ' /See �044 .$asivesss sud Psa7,j�.esxonx Coile: T�'''°oer � ... .� ..�... :�� . ,�c ; �" _..;. � � txuSor's Tacea.s'e Law doe,sso2 app7y fa Ass a� 'op ' � ` _ � � ` ;?:y � --'h'��' ,�_ � . � $ro?8r'tY wbo S�es�r�or ianproaes i8�reou,�and wbo does`� z "' ', '"�. .�. ._��` ,..�: - - sacb woa�k basn,se/,/� ided bbmt sue�ssna�is�vem¢mis -'� ..:._._ , __«, ... ....,. . .. , .......: ,x. - �. � .C. _ , 3 � , t^ 'l pI'09J 9 . t� �: _ �,�f{ 4z� F� b s�g r.s�i�m'd�rov¢�ii�a�fsold�tuitriisbone�� of' +� °� .��. ... . ` � . man/rletiort, tbs awn�nbuiYdea�cuiXY baue.8be.� �,,.,,._� �_ .. . _ .: a n � :'�'y�,3��� 'C���'k.r�';.�rz`� �}1n'ovi�tbaz ba d��oa eSx�ar tmprcea�e"Tur sbe e« pury,ose aale.8 .��, �� ;�, � .,_ ..� _ . - --"�� ' � � 1'�t�.....�, r C� :ErtJ!'irr �b�a.� '��ry-'� :. i ., , l ... . . � .._ � +� R .. gypp��. .:. ,� . �- . � .r :; � �,'G�a 'i �.pL l �t ,.d. ��eu.b ¢ �.��.._a��t,�.���,�,ni����- � . . �,i . �" y � - . � � `r... . ._ � p if pt .,: . ... '' � �: -t Y'�v�ak�"�a �OQ'��l1SfQ'dS6ffi �4�'�. � �, � � . . . � 9 � l]Q A�l/. d .� .����g�`dt �v .�^ ,tb ,.��. ' `5 _. - �` �"'- -f� �. � 'a", 1�, ;�: J� . £ � � �� �. � °skz ,._,.,�!,� . '. I f b £ � . _ �` ;'. �' � �. � — _ _ . .� � � �r� �, � �3wmer .. �_� � � a � h � � _w_ , �,,�; . , _ _ � ., ��- _.»,.,..�� _...�_�_ .:. 1'►dSPBCTOR'S MbTE� �-: ..,.._�..,�..�.. ...�.. ,_��.,�..::�, �..-� .. �'.':�:, ._�.,;::.: _ . �r. i i '�.�3 ' . . _- �; i - � w�r Y��-. ,t a.,.�,��: . � �' . ,�, 3 . � ��� ��,� d..� .i :� � �-� �v.-.���ti� � . , a ybr e7� Y � 't.JW Fa 1 �".,t?� ,'a. �7'.�:'. F b ...}.. ...%w. '� .2. x �s'�'h`�f, �� ';;� Y '� � �, . ,. .. :, . v " '... . +yt:� " � , , { , �� '?�""'" s ^�.£ Fs t ,s F"`�✓��� .� ,.3 t�� t, . � � �. _ ;k .. : _ _ " _. iL . �-���'c�����?�"�tmN,�nr������'����. — .� �����'. . .. t.,�� r :� . .. .. ,- ��. � . . . � 4.- ��•�_ , - .i..zr. »�e::�,r: " r� �'�3��-� :�.i .. � . . , ,�: . .r. ... . ,.,. � � , �,^,. , .. „. ' � -:' ,... . : Yse� ., .: . . . ,,1