Loading...
HomeMy WebLinkAbout1760A WORKERS'COMPENSATION DECLARATION � �� -� � ' � �� � � � � � � � � . ,. .. . . . � . . �. .... .... . ��. � '. I hereby affirm ihai I ha e�a-cert ficate of consent�to self . ..: . ....- . .... .:. : . . . . . . . . . �. . ... .. . . . . . . � nsure,or a certif'mte of Wo�kers'Compensation Insuronte,or � �6n6a4o � - ��� �� � �� a CE-BOB'lREV 8/811. . .. ' . .. ., ...- . � . ., ,�....,._.:-.., .�v.:,:., ....,...- �.,::.,:�.. . a certified copy ihereof(Sec.3860,lab C.) � � - p � Policy No. ,,'Company.. . . . . , . . . . Ps:. ... .. . . .� ...� � •t1PPLItAT(ON���C�������tM�T _. . _ 'A7 .. . ❑Ce tified copy is hereby furnished. � � SE•Y�R � SEW�►G�`�I�POSAL ertified copy is filed wirh the coun buildin p COUNTY OF LO$J►W�SE[E"$ " ���l�j�.D�F1Gi4M�Sl�IF�1`S� " '� `'� " ` ty g in5 ection ���-�� deparrment. � _ .. . ... ....... .:...... ........�., :. .,. .....„., ..., Dare ,4' I cant FOR APPUCA'NTTO FILL IN f j ` f CONNECTION DATA ' ��„�4 �-�� This sectionRnreed ot be,�om�ryte��fLtheN�����s� � ���. � LL � . ..��. PP .» - _..J ... .. ..._ _ . euaoiNc � . - E, �� ... . �. AD�RFSS L �..r � STATION �.,L�� DEPTH � . ( � p fk�nvO�veCl by Ihe �pCAIITV R yy� MaNHOIE REfERENCE ' UPVER ,�permit'is for one hundred dollars(5100)or less) � .� NEAREST 1 TYFE OF CUNNECTION IEN6 H FROM� . ..Y . , ...P .: ......,.. ...... ..�. .. ceoss st. �, ^ . ��I ce hf� tFoi in the erformance of the work far which this v. cuae P.,.. nn.�.70 a.t. �� ,� perm t s issued,I shall not employ any person n any manner - r, , ' so as to 6emme sub�ed to the Workers'Compenwt on Laws. a.c ruo. OWNER h O �' G1h.S CO.IMP.NO. � - � JOB NO. � � � � ��� ` Dp p�^ �H � �� �RUNK PERMIT n10. ROAD PERMI7 NO.�� � �s � Date �APPIiCanf � ADDRE55 ��� IVOTICE TO APPLICANT �{ OfiB��TOkll9�ih15 Cerfificaie Of � / ��/dJ AFFIDAVIT' WAIVER EASEMENi RECOKD.INSTR.NO. DATE � CITV TEL NO, ! 7 / :"' . ��Exemption,� yo� skiauld bemme s�6�ect to �he Workers'� •• ;���Compensation provisions af the Lobor code, ou musr.forthwith �ECA � � � As Y �ESCRIPiION LOTNO. NWY.ORST.WIDENING ' 1. "comply with such prov;ions or ths permit shall be deemed- .„� , _ � � �i'evoked. .:^,. . ,... e�oa iRAC� ft STATE ENCR0.4CNMENT.. .. ...... .. '....... q- �� � UCENSED�GONTRAC70RS DFCLA'12iC �y�. /� PeRMir Na --- Y � � ... ' PIOvTIC�f��..::..... .... �...: O V l/ NO.OF BLDGS, ....... �� SIZEOf!OT NOWONIOT �-�I hereb aff rm tha�I om Ircensed under sions of Chapter use oF t - .��9(commencing with Section 7000)�of Drvision 3 of the BUSI- gUIIDINGS i YG�G�P anx�s � �.�nes's`and Professions Code,ond my I cense is��in full force and � ... . .. �:�effe[�. , CONTRACTOR ��-. CONNERION CHARGE FEE . . � ..;: .. : . ... .� ;. . ...... . � LiC2f15B NUTF>C� LiC.CIq55 AD�RE55 REIMBURSEMENi FEE �. '- CO�ifdCtO�, � ��DG12 � � �� � � / , • . 1 �f �ISTRICITp. GRpL'P MAP . . .PROCESSE�BY....._ . . , . Crtr h h!a�' TEi.N . � i-"/ � �7 � .,C f� ./ BK PG � . ❑I om exem t�nder Sec �� STAh .7 ry�— _ J–� _ P , of the L.A.Co. . u[cNSE No. / c�ps5 .�'� :� �"f �i �/�� /fi?" �� ,� PlumbingCodeand/orSec �� � of}he � NO. D[SCRtPTIONOFWORK �EE � -� � . . � .... FINAI - 9 � '•��, HOUSESEWERCONNEC!IIJG.iO��� ��''�' � � j pqTp l���� � .. � .. . ..�:: , � �... � .�� Puaucsewea� . . . fj' VALI TION . .. �� B:&P.�Code for tFe follo n reason „ 5ecric rnNKl SeernGe aii oa � DQ�e�'� � � � ' PI5 qN�!OR ORAINF�EID "' FINA: � � �� HOUSE SEWER CONNECTING TO' ' �' ' BY . ..�� ':�:: . '�.: �-.: . ?RiVATEDIS°OSALSVSTEN� ... . . . . $Ign41UYE CONNEC7ADDITIONALBLDG.OR ' ' ' ' , -� � OWNER BUILDEI2�b�E�CA`ffA71dN "'""`." `".„."",. woRK To House setveR' � � � ��" M OVERfLOW SEEPAGE PIT,DRAINPIEID �� I hereby affirm�thal I am exempt from ihe Contrattor's License exrH_cessdoo�,oe wett,MaNHoie � ���� �� , Law for the following reason(S2CiOf1�O$�S,BUISItC55 OfHJ PYO- AITER.REPAIR OR ABANDON HOUSE " ' '� - fCS5iOn5 COCIeJ: SEWEROR DISVOSAL�SVSTEM- ' � " - _ _ _ �I `1a^vA :� ❑ I,as owner of Jhe properly,or my employees with wages as � - � -��:-� � iheir sole compensation,will do rhe work and ihe stru<ture ;;� � e m ; O � �� , is nof intanded or offered for sple(Section 7044,�Bus�ness - ����� � � � � � and Profess�ions Code). - � . OWNER'$ � Permit 5 J`y.���' ' ❑I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE r' ' � �-L � �� I censed confraciors to construct the project($eciion 7044 - i HqvE ai rNis�Ah n CONTRAC7-vJ�IH iHE'�HEREiN-Na�E��[Oti7W,CTOR 70 " � r �%�- �� Business and Profess ons Code) - . CONNECi THE 4BOVEbESCRB �2XISiING'DWELLIflG i0'TFIE'PUBCIC"SEV7FR "_�' � � � C0135TRUCYION LENDING AGERCY " "'�" """`�" �- 'Y/ [�� , ' �f,r('.. � � � . . ...� �SIGNED THIS "�� �pF �� �! • 19Q,� . � �tI,�:J J L. .. �I hereby aff'rm thai there is a const uchon lending agency � for the performance of �he work for which ths permir 5 OWNEROR . ��, � �issued(Sec.3097,Gv.C) ���� ��"' -oWNesSa�ENT - ..:, ..... , . - :...,. � .�. •, ;... . �. �....... .- .aooeess Y :s_�'. , �.Lender'sName � -.�.Lender's Add ess �'::.. . :.: ��.�:` ` . ,s. �� � .,......�..,.,..�W � ........�..._..._........_ ......_.�_. __•..�..._.._....,,_,....... ........ _,...._........_.._......_.... . _.,_,......,_......_.. .._.., _...._,..:... ....__._ _.._.,__,.. ��'�I certify'ihot I have read�this appLcotion and state that the � � . ;`�above information is correct.I agree to comply with all-County � � � � . � � or8inon�ces and Slate laws regulating.Plumbing.and Sewers, . � � . ��'drid hereby autho�ize representotives of this County�o�enter � � .u�3 e above-me tion/e''d� property for inspaction purposes. � � � -� �� � � � � �- ' � .-- ��•/{tA�i��`' 9_-� -�3 �_. __ ._. . ._ _ gnofure of Permi eR e - , ote . SEE REVERSE FOR E%PLIiNATtlRYYANGUAG�� - - �� - ���- ��- - � -_ ___„_ , . . . - i;d3e FCT�s�(5��9C:ss � �� ..::., . . � . . ... . . ' _� �____„_ ' C�4�;7I'dE�'�LIII„L�ER aJ��'LPiILA'I`IOIV" � f �� �. .. : m _ . ._, - . ���3�9��°��p���� DATE NSPKiOR'SSIGNATURE ' . - • - �� �. �`{Si�VEIYl[ i:".�. ":CzlkAjJ::'OI.tlI:Y..�..011[idCiOi'S ...., ... ..:..... . ..�_. .. _____—___^—_.—_--__- , en�e iaz�iot ei*c � ac.3ig reason lSectdoos�%031.5, .,. NEWHD'JSESEWER � � .. . .. �u, � r �'c,st'3S C.11n '' .. . . .•ex_ u �.E nl / ! Y . .'�' �" caunty �.. . .� . ..:._ . _ � �—_ � � CANNECiA�Ciiioun� .. . . ...-. . , , .. .,,. ... . _ .. .. . ... � u�F.cn reqs-�es a,h„r� Ers cc:i. r.<.., ¢EFcr i±r.�rove, � BIiILDING OR WORK " ""' ` � � . ' � �� - '� � demr aa, r r�yrc•r a>> tru t+er f r r t :u xs��eq,^:ce; - $EPTICTA�iK.SEF.a,�It�S� .. - . —�— ,�. . .;. ...... "__--_.—:_'—_ . : . � .. . � ... . ...,.,....,. . . . .... :. _. � �AN�/OR 4RA!Nfl_L'J , .. _ , . , CISC. leCf# tktrt tatJj7l flJO!t�fT Ct)�SGT.Y.SC E7�tIB F . . —� -.�... . � - . . � __ qned ta� � e�� �at fir iF -Le535 w hurau¢ssE tn t'oe , ; cess��❑ DRYWELL❑ - ��� ' �: � .- :.:: . �.—�— � - � -' �_�--- .... . . n:�..,.on<.> sfi., � � f - . � . . .�.:. .�,.� .. . Y 1 !�^r::xsc8vr s i.scewss Lam C6¢ter 9 atiea,�ae�nia.s=_w=_e oa ;... , .."�� .. .... . ; �. .. ,_. .. . �� . . �- -- (cr rn Ye:ar;{u�szLr&e �, 7�'L�Cr'..of.+7svsalors'3 of Eha sewnceoisrosni�svs�t ---�----_ . .. .. ........._.___.� �,...._..��.w._,___��.,. .. ... ... .. p� ... ness�e<rc3�:�rejess�n-s �'c1e%o^thH? Z•o ir. C.YB4Hji2 . ascoNN[er o!uG nNO� " � � � .� �,_. � ��' � �- � � - � E3iere�rr,s�x a^sd 8L-e G•csz:joa�th¢�n a�ed•,xer.e;�tiott.Aicy ABANDaN HOUSE SEWER � ' "" --'- . � . -� __'__ .. .. . . .. . _ � � 9ACKFILL SE�!�'ANKS n ... -- -- . . . '.: � . . , . ...� : . �-liiOI.Zt8095 r.SCC 4 'e.121J�1 J�,Jy u43y }Yt5.[Rfbi..fGP L ACYtilit - seev a,ri5�❑ Ce55voo s❑ ,a. ._ .. s hlects 51 e L ._Nx tn a-sv d p r t3�ra,`�aa-r o,e E`nan .m.m.,., �,:. ._ m :...., i �,2 ..� q c� :..�'� i �S�.. . . ... (ve!�u.dr�drlPurs(�5:70� s . ... ..,. ., :,., ,. .. �..... , .... .. ' . ..,. . �> . ^� ,`. - - .,. ❑L�as tna owner o; tz g�i�opesty wii:3o ihe work,and : ., . , . .:..: . .. --'.'—-�-- ,. , ._ . s ... �. ,. � ; � , � . ..c..: .� :K.. , .. '. ; .,.. _ . �,.° :. :" e a r.��. e ,aoY xnYe.�zd or o f re for>.c._.. r Y 3 5s . ;:��.. . .......__;. . � .__ .... . .;.......... ...__.. ... -. �_; .. .�:- ' :_.:.. ' � . . :.:: .�. .3=�. 7C/,+» �.e:iinesi.a:sra"�v�fesss,,:s�Ceda. T�'Q Car_ :-.. � _ .,: . � .,,.;, ,r..,: ..,.. . ,��.�:. . . . ..,.... .: ........ ...... ......_. . .. 'i .. .� . .. tra-tr>'Q's Lscen;¢'La'x..���oes�noe ap,E31y tn a:s.oxe�ner nf . .. _ ..... ._. . . � _._. � " ,:. ..-.: .a.� ��; ,�J '.. � � . prop�r�;y wha 5 x`ds sn Oroacs t�eruon�and wha�drse.e � '„ � � . � . . _ ..... . . .. . . .,.:., �� � s ch.uurk 1 r e�,��r�v��nd f,S:a SffiCII.4Y�1}i'LVPl9iCf.GS ........ ..................... ..... . .... .-.� . ��::. �"� .. . .. . �. .. . .�. . ....:. . . ' _... . „ �_ .!�.,.. .� • • •",... . � � ... ap�.rao¢intsnFrc�yr.�ffe�.ev joc s¢ls.P:howevr.>� tha - �". _._.:........ ....... . :c�__. -___.... ..�. .. —::.� ... .�_ " .: ... . - ,brs4�dzng..s�,ros{sov�:�a�a:ss.soed xy�s�:�ive ome.year of _ '�_.._ _ _. ._ . ...,.. :_�..'.. . ..._ ... . ... . ':_� . �'—..:�� � :...., :.'._�-�. � ..�.,....., ..� _ . .,':��.�completior, 5be cz»rer-ir�i�er v:.•ill bxve the Gunlea .r � . : ,_.,, . . -. � �.., ::.. ; � �:: .� . :- . . j fi:-r.v'r..g t'r.at Fie�iG.^.ot baz.sll er�imprcv¢for tfie ;' - .. . ._ ......_...... .... ...... ._. ��:.. ....._.'... . :a, .;... :;.:'_ .. ... , . . .... .� �. � �.: : . �. . :., - .. ... �r t�,cse cj sale.) . , . .;., -. . -• ,��. ��� �:. „ �. . . .. .. ... . . . . .. . .. . .. . ,. . . . ... ._ ;. ........ .. ... . � _ . ., �,.. ,,... . , . . .'�� � , �,_ , ,, : :aen ezer��t under 5ec. ;`, ' . _ _, . ..,� , .' ti . ��'?.6�.fcr�his z.�sosi_ . ..._. -- _.. _. . . . , „ l'a�te.-- ; _.;. . -: s':_. ",=. ' . �w�_er_ . __ ... . J �_. ---- ..... _..,, ;. , ,.,,,�.,,;�., ..;,_. � ,; . , :. iR�PECY08'S NQTE5 . .. . . . :,,, .... �. . . ;•..-,� .,;,�,� .,:, � �ti t , . . . .�. : .. . .. ..... _ ...... . . ... , � , ._ ,y,_ . . . .. _ . '�: n .. y .. .. . . .. . ... ..... .__....____ ........_,,.. _._ _...__,...._. , ,.....,, ' .'. ,_.�,....,�_ . . _ �,. . .. . . � .. . �. � . ... .� ,.,_.qq -, s�..,: ..,,....>.F_ . .. .;.? ..__.,_:c,,.-,. . . . .,.. . ., : � • .,, . ,. . . . , . . . . . .. . . _ ....., ..... ... . - . . ! . . . .. ..., rM+�vAa�.,,is .. � . ......... ........__.a ...w».�+ ,.�....-� �..w�+.a�.:wp��aqr�!=t.mud�.wy .�. �-..'vytyµ��w?'si!w���Ti3+<,h3^'2rp+lueW'.tw%rr�u�Gt...h+�il�uv:b'.L�i-..:4�i�vlC�uu u�..wW�4,,.4.v1:._.:.:.�_..: '.. . '..0 � . ...� . �.. .. . . . � . . .... ..,... ..�.- ..,. ..�n. ..i�.,:.�. �..avr uY i r -..,.. . . . ............. . . rJ'MA..: .n'm.rv �.re.. . � -. . .. ,. '. . q . � _ 3..,. : . . . . '� .� ' . . . ..� 1 . . . l_ . v. ».... .,�;.. `_`_� ' , . .. `y ��g4 •�e,. . . . . � � ..:t3'.vd� u�^.N ... . . . , � . � . . ...._. .. ..,. ..1 .y, :.. µ,. .w .� �.:"FiF*' w�..... .n.,_ .. � ., , ...., ,.. ,..... ... .... ... . r+�:�..: � ...,.,:.. - ' V;:}t ��.i� ;�. ..� ,. . .. . . . y ... . �. ' . . . , ... .. . . . - � . . .,2b :.,. ..... . .. ,,:;?: .: . , . . . .... .. .... . . ........ . . . . - � .. ...,.....�_..............�.�. ...,..,....... ....,....:.... ,..;.�...,,..r , i..w.::..�_ .._vr�..ai�.x .. . :.':n.n.� .4-,::�. , _ �.�JW-' .... . . . . , YrF+ ,,,'Rv.x �.y^.,',a: .4e{s15Fc-v . . .. ....... , ..:......... .,..,...�..... ............._, r-.s..»..�:r ..,.......,�.. »-'...,>n... .. _ ...,�,..,... . ..,...y�,. « ...-.�t.:.e .. ,. � ..:. _�... -� . ,�.�.y.�� .,...,�. ,,._. ---- ,. ,,, , .� �,..-.�,..., � , .,�. _