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HomeMy WebLinkAbout1490A . WORKERS,COMpENSATICSFIDECT`d�X�'�'.-O'�'�,,:- �....�» ....,...... . >� ,c: . . . ...n.-,...�. .,_ . r...,.....,....... ....m._.,� .� .u.....,„- :; f }�ereby._affirm that I have a;c,�r�rfimte of consem�to self � - � inturE ar a eert f cate of Worke s Comp'eYisahon InsUrance,'or""'�� xtadaxb" '•�,-- " ��� ' ' ' � ' - �� f ,,. _.W, . � . . . ` �+ce h,f ed cop 1Pie.rao{(Sec:"�9�0,Lab C}�� `�� ''�'eae frzev.eiei� .':'_ """ /� " /�"� /� �+/'����` '". ...� , . �, - �r� . - ,.�> \in �� s .a....�ca.«�..w�`,�..:.,._w....�,.,.....�.�,..��..���- �o�I�cy Nc�a�����}�Company'c�'�. F'U.�1C� � Os � e'4PP���\+.r/1��.��Vr't�y����y i- � �C�rt f y� I�' by furnished. � �" g in5pection � �.., .. .., S,_�WG�...7GYYf1� -' .�a,�„ .. .. ..,. d i re , � , - �.�.�.u. .. �....�...�.,.... .�:n ,_.��.w ._� ._�Cerofied copy�is'�f�led wtlh the couhi buildm BV�L�'�NGANp$q-���---•-_—�---- �� �� �,;��;�.a;��,�s� FOR APP I�1�T I"�J bs'"���C;'���5.....�„�.,.,.,.�.- ,. � �epariment �. _ . , � bote i� � Appl ca�t +�'�QAi'ci�1 -� _�••-�«..�• � . t� t � c�irr�f��a�'E'c��. CONNEtT101�bdT�l �",.` ,�., BUILDMG ;� ',�°"'' ;r` ,��„COA1iPE'n1S�1'(��5F7�Y���A`"�GE „' ,' ao�aess �� srarior.r. -_.. nevrH � � � �. (fhis section need not be completed i the work invalved�by the p� , ��$ ' � rnnNHo�e�a€peaer�te � uavEa� ., ,. � .. - �ocnurv . ..,, . . , ..., . .. . , iowEa �Serm t is for one hund ed dollars($100 or less. - � �,, 7 cart�'y tha� n the performance of rhe work'fo wh�ch}his caosssr. � � �" TYPEOFWt�NECTbN . �NGtHFROM - permit is issued I shall nvt atnploy any p�rson irc arry manner ��.' �. � - - � M . s'b&s fo becpme sub�ect ro ihe Workers Compensation Laws � ewNeR�� .�i�� '� G� �R _�y v` �P�.'' �' im l Y'k^'� ,a § �'i-��i'jt�'}�' - CO IMi NO. P C NOl YO� . Pl C ,- . t� � �,b ' � JOB NO , Date� ' A I cant�k����� .,�� f ��. � �IA� . �Q.'� .._..� T� . .m � • iRUNK PEfFMIYN6 �� RbAD PER1�11"NO.v�� ,u PP � ADDFE55 .. ' KI�TI�E��APP�1�.`��°"`If�a{`ter mak ng 1 i�4er}ifitqte of�� �� � � on - mpi on you shouJd 6ecome subject��to the Wo�kers' �'�� ' n) TE[.tio � ��, � AF i vi w i F i �.S VER EASEMENT RECOR�INSTR NO-. DATE- �*rpensaiwn prov srons of the Labor code au must forthwith � �E�At �� ��� � - �.- . � Y � oESCRIPTION 4aT O '� MwV pR5i.�WIDENING" �' r nply w_�h such provis�ons or ih s permil sholl be deemed � _ „ � � - ' " ' ' ���"- 'revoked � � - �. - etocK'�� ' rRacr �j���}� � y+ ag�k STAiE ENCk6ACFIfvIENT""""" � ��y'*'° . LI�tN�U Cf������ ,w., . �W � SIZEDFCOT �OFBCdG5;' PERMITNO. � Y>�~' ��he e6y aNrm t1iai�am license5�onder prov�sions of Chapter A � � . No tlN'tor . � � 9 Ccommendng w�h�Sectiori 700�0)o#Drv sion'3�of the��Busr � auiioiN�s '�3'�'�' �e`q��' �� ` . .,. --. "n°�e`"`s�$�`d Pro(essions,COde and my I�cense i5 n f�ll iorce and . -� ainRGEs�: �e��eci - � F�i�r�`i� �i � � .� ., . . u t ; : :' ��� � ... CONTRACTOR , CONNECF�ON-CHARGEF�E "" ' - license Number 4-?��$7 L c Ciass nnoR�sS � ' .� ; -.y3.� t�.,��$5.�5,� �' � ' {+ �t y�.: , t; . .,._ . ,. REIMBURS MENT FEE . . , ..�'' . �.ContfaCto�,� H'T'�(aQj{��'E'� Da(e,�����t") . ^•. .°:. .•.�• �:_. • .-..�. • . ' �;. .❑ISiRICTNO. GROUP.,. MAP�� `PkOCE55E�fiY'"".,.. X'�n,:a w 'T___ C TY �tEL NO, . V ��❑I ar{i ezempt vnderSec � of the L A Co � �'°iE � - 8p - �u ax vc� Z : y 1,;••'�,� m �3N`!"4x +dh. - : . -: LICENSEND• . . U CLA55 w � C� � ' � � A 's PlumbingCodeand/or5ec ofihe N� �� DESCRIPtiON'tSKVJOf1R' �E '"' � � �= „� c:� .. i ' z ' ' .; '.. HO..SESEVJERCOIVNFCY(NG"YU FINaI � , B 8 6 Code for the folfow ng reason e4euc seweR °ATE VA�IDATION r . . .� 'HOVSESEW'k":O ✓��� y � .� . , � �` ' � rS �C3 �"��v"-� . .. _ �� � t ,. t� «..: pEPTIA(�A/O ORPN ECb�R �� ;`, FINAL '� . -,.^ �.....�. I�Q C A :. , -, :�.,.,:.. �, ,.�. �v�" e-��:,e. �. C NN I t'j T6� , . .. :., BV _ "� �gnoture - � 'PRNATE oi5`�l3SAP5�� � , ,. CONNECT r1pD1TTONAt mI.DG"0�3.. .'.' . , . . . .. . o1r✓�Ek°9'l�lY°b"Ef3,"6E�Ll��°i�<$T:i"' ""°" woaK*oHou `stv✓ea ��f hereby aff rm that�qm exempt trom the Contractor s Ucense ovERFiow seePa�e v�t�eqiNrie�p . ' . �'�'� 4�9�:(�A. ' EXYN CE55 i�6C;6kY',�EL."hrAfUHOIE ' � . � .T , , �law�or the#qllowing ieasan(Secton 7037 5 0u sness an��Pro �' qirea,Rep R�UR A ry�,owHpUSE � � F '�'�sonsCode) � s�euoxots@d5a�,�"si�a'-�. .. . . � } .�z`�c a o�..� '� � � � I os owner of ihefproperty,or my e'mployees w�th wages as - � � � � ;`� �� €.� rk ond the strucfore .... � . . � -[�+t���'];.�.J�.�� ,�� � :,' `�rs not n ended or ofter d fo�ale�Sec��� � �� � � � - P �4r�. � S ( tion'7044,'Business � .�. . .-,"..••,-^-, ..° �, dnd Pryfessions Code} �-.. ' QWhJE�'$ Pe(ritit � g � �� 0� . . � _ s, ��j:��.(����� � . ❑� as owner o4 th�property,am exclusively contracting:wdh AUTHC'�RIZ�.�'r`(�f�l TOTA4 FEE licensed contracrors to construct}he pTo�etf(Section�7044; �� �- � '` � Q � . - � � i,'��i�!�"��v� . I HAVE'AT TH15�ATE A�CON7WA"C'f"WiTF" HE',flEfj IFI�N"AGfE6"CONiRA[TO4,TO' �usiness and P o�essions Code) �� � cpNNKrrHEngove'oE`3tei�6�5YfNGbWE[Cii'J'2;'W,¢T1iE'6U�1'i�'$`c�ypk, � � � -' cOI�SrR�CT1°�5�7NUK",4��"""""�`°'�''°"°""'�'" c'� p� . „I hereby affvm ihot there rs o CCnsiructiorn ien�irng agshc� -� SIGNEDTHIS pq-�pp ,ar �yp�9 , . . . . - -. . `�for ihe performance of the woek fo wh ch th s.perm t s - ow�lER Oa �� , . �. - ��issogd($ep 3097 Crv C) OwNESS�AGE�h �' .� • ' .- �.ADDRF55� �"M' - .Cender s Ngme �� . "�'� t -� fi1 .�`i:f .f ...:l ,,.t.'n ", z.v'i- .,.;::.1 � ,:' e. ,, ,.. ��St-x�..Xr-4"s�`;_ea'�Sa.ke��a.:�r x ev'-+) . :�<n .w,.,.... . m ,ro.E. , ....- . ....,. ..:. ..... . ._.. . .._ . Le cJersAddress _ . , .�. �. . . . . . . �� ... .. .. . .. , .._. ._.... . . .�.. .,�I ce idy ftipt I�have��reod ihis appl cahorf�and Sipie ihat�}he . �- � � -,����above i.nfdrmatio�rr ts.torrect.-I.agree�o comply w�ih-a16Counfy � �� � � � ?`otdinances.pnd State.;laws:regu�lating Plumbing and Sewers, � � � � - � ' � � � �� � � <=and}�e eby authon�e.representatives of ihi4,County'iq enler ��-� � '� � �� � � �� �� ��-- - - � - � � "vpon th�above menrioned property for nspecf on pohppses. � `�` °-" � -�- � ����� '��' � �� �� ����� �� �-- - � � .�, da ` ��.,:�m".]� ,�,..:-. .r.,����. � /�:. ..,, .. � ,: � , .- :.: �, ... . . . :�,�.�p�y� "�iK.f ID Mry.L�W' Ll��7�.b � �_ _ _ . . . . . Signature o-f-Perm itee Date SEE R'�VERi"�FO'YCp7('I IA�YX'T6�V"�'7�'t�`i;'�',(�"�„'•'"' "'"" '""'•.`""•' """ ' '",.' ""•.'••""""" """'"'" -`."`".^"`�-. E :� ����.=;�i�a�z��,� ���,�vv.�,����a .�� �:a�.�.s.��r�a���.'� ��,�,r'',�>_