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HomeMy WebLinkAbout1763A ... . . .. . .. _....__ .... �.. . ._ . ,.. . . . .__...._ . . . ._._.. . _ WORKERS'COMPENSRTION���ECCARAYl0�1�"���� � � �. �. . � � � �q I hereby aFfirm that I have a certificate of consent�to self �" insure,or a cerfificate of Workers'Compensation Insuronce,or ��-� ��6asc . � � ,�, ,,, __. . . .. .. GE BOB IREV.'B/81�. ........ ... .. . .. ., . '.: . �,, w ..`�k ...�.,t.w. ,.,.-.�:_�. K,t .. .�.- o certified copy thereof(Sec.3800,Lob C.} � � �PpLfC�ATIQ�V �di���'�R�IA�T PolcyNo CompanY . . � ___.,......,.:.@s ... .. ... . . . . .... � ....� -_ . . _. ... . . . _. ... ,A, p g y�� "� �c ,'�y-.,� ..� . � ❑Ce t�fied copY�s hereby furnished. .. ... . . . S�YYER " JEYYA�E V�J�d�AL „ ._c.. .,._ .,... ,_ _.. . ..,. -� .,....». .,.,.W . ., .. ..... .. ..,. ._ _ ,_.,..�„�. .,....� ._ � ..,..,.�..., �Ce�ified capy is filed wirh rhe county building inspection COUNTY OF`!"Cj$�1I�Z'r`�L�S BUlLDING AND SAFETY .. �. . ..�deparlmem. ._. _,....._..... ..: .. ..,: .... ..� ;:��� �� . . _:, . ;. � ..._.. . .. Dore_ ' Appl cam .-.. FCR APPLICANT Tf5 FILL IN . �. �-f!�� CONNECTION DATA� � � "� �CERTIFICATE O�EX€'MPYf�fR�M��O'R�S"'� '��•� . ��:���. .. . .. .... ....-� . . ...-,."� . ._. , BUILDIN6 . Q • SiATION ��- � � DEPTH � <OMPENS�STION INSURi\NCE ��� �� � - � aooae;s ,� � (7h s seetion need not be mmple7ed if the work involved by the i��q.iT� � ' K ,ewNr+oie ReFeqeNCE� '�-��� ��' � i°PER.- pe�mit is for one hundred dollors($100)or less.) - � . . . - � � . , : .•..... NEAREST . / " tYP�OFCYNJIdFC�IbN"...... �� I cenify�rhai in �he-performance of the work for wh�ch rhis caosssr. ieNcrnFaoM . . .. . . � Q r ��Ib'��P . Y. CVRB..:.. P.L. M.L.iOP.L �: � - permit is issued,I shall not em lo an "�"-' "" . -" ` ` ��- '=_ p y y person m any manner � / - p.C.r�6. -� so as to become subjecr to the Wo kers'CompenSatron Laws . . ewNER � /�(^G�, �� � � (f h �' co.innv.NO. � �� ��� �oe No. ,.� ,.:f �`��7� � .. . . . ,.. .. _ . ...... Ty :. .., ..., ..: .:: . . .. �� '�'� �- � - � �� hWIL � y � /� iRUNNPFFMIINO ��� � ROP.DPERMITNO '� �� Do�e � APPI m�t ��� v f.h �'!a �s� _ . _..,, � , ..._..�.� �� ' .+�: .�� -• �- �"-" � " ----- ' � ' AFFIDAVI� VJAIVER EASEMENi RECORD INSiR'NO DATE ° � NO71`CE�70 A�PLICANT.�If,'after�making tha Certificate af � arv re�No. �"`d � �"" Ezemptian,� you should become subject to the Workers' .�E�A. � � �� � � . .'� ,.'-� ''� � - Compensation provisions of ihe Lobor mde,you must forthwith oesceiarion . ,.orrvo. ��� � � �' �� ����� ' � .. HWY.OR ST.�WIDFNING" �'- .. cdmply with such provisions or ihis permit sholl be deemed r+�} U � � - ---�� ��-�-��_�� - � R .. fC oked. . , . :... a�ocK iRACT J [ / � . StAiE ENCROACHMENT , ,... . .� - - � _ ,: � ..,. ".. ' 6r :.m.....,v-..:,�.:�:al � ..�. .. .,.....' ..... PE4MIT NO. . �'•: LICENSED'�ONtf�X+CYOFF3�'[5EC'�tik�CYY013. ."�" No:Or e�ocs" .._ . ...--. -�-._. I hereby affrtm that I am licensed under provisions of Chopler SREOFiOT (�f�}d Q Nowgu.oT �� ' . U'SE OF� ^ y ' ..._. ......._ . . �. ��9��(commencing with Section 7000)of Division 3 of�the Busi- �. guim�Ncs � n sa �,5` G' CHC� cHqRGEs � .:-,_;,�,;,,_,s ness`6Fd�Professions Code,and my hcense is n full force and _ � � - . .- ' e{feCt. CONTRACiCR G y�y.' CONNER�ON CHARGE FEE : . . , , _ . _....._.. License�Numbar � � � � L�c.Class� ... _... � ,f,, aeimeuaseMeNrFee �� �" � �' � ���� ��� � .. . ..;.. . .,, ADDRESS , CO�t�aC10� � �OtliC �� 7 �!y^ �iSiRICT NO. GR UP MAP PROCESSED 8� .....___. CITY -y�. 2 TEL. . ,7� � D �. . .�_. . ...:.: �.. ._ . . . -� � ❑ I am exem t unde Sec .. of the L.A Co srA1e� �] }^� J�' q uc. C� � �� �K/✓� �� P , . LICENSE NO. � / ✓ J /^� C1A55 � / , ' ..:-. �. -. ,:_ , .::':. ` P�umbing Code and/o Sec. �. o41he .�, No. DESCRIPIION OF WORK __FEE,, , .,,.,.,. ,..,.,.„ F�Nqi � . .- �.; '�' ,.. HOUSE�EWERCON�ECTINGTO . ' DATE —� f-j2� VALIDATION �� 6 &P.Code for�ihe followtng reason � c��;aucSEweR . _.. , . ✓✓ !✓ . .�'..... .......� "'. SEPTIC TANK,SEEPAGE Pi'OR ` � � G:?5 AND:OR ORAINFIELD � � ' FINAL _ _ �a19 YOUSE SEwE2 COtiNECiING TO � � . gY .. , ., ..:.�...�.. ',. �,'., ., . '... ''....:. r ....- .,'..'�' PRIVATE-DISPOcAL 5:'STEM. . . �. � $I JnOtU�2 ����� �-��-- .�+.=+.•�' CONNEC7 A�DInCNAI BIDG-.OR '�� � ' " � """" '�vCRK 10 HOJSE SEWER � .:�" OWNER-BUILDER DECLARATION oveec�owseevnce vrt,ozpiyFleto� � �� , I hereby affirm thai I am exemptfrom the Contracto's License .__.,_. exrN..cessaooi,oevm�i�,�MnrvHoie �- ��'� - - law for the toliowing reoson(SectOn 7031.5,BUIS�eS5�Ot1tI Pf0- AITER,REPAIR(Yi ABANDON HOUSE� . ... . .. . . '' feS5iOn5 COlIZJ: . . , _ SE�NER OR�15PO5AL SYS7EM { � �. ❑I,as owner of ihe properiy,or my employees w�+h wages as .- � �� � �z��J j . _ .� iheir sole compensation,will do the wqrk and ihe shuciure - :;�, o e o j Q is�not intended or offered for gale(Section 7044;Business - � � �"�� . �. �,. ;��C� . ❑nd Professions Code). �WNER'S Permit S �' � � ����tJ\' ❑I,as owner of the property,am exclusively wntratting with AUTHORIZAT��N TOTAL FEE� � � licensed COnffOC10r5 f0 COnSffuC1 ff12 p�ojeCi($ecfiOn 7�4d, I HAVE Ai iMiS DATE A,CONTRACT WITF-T:IE HEREIN Ni'ME�tONi 4CiOW iC ^ � ° r �.�?�;U � � Business and Profesvons Code) CONNECT THE FBOVE DESCRi9EISFXYSTINGOWE.C(R:i.'Tb THELU$LIC SEIMEF'�� � �� CdNSTRiJ-CTIOIJ�LENDING AGEf3CY '��''`� ��� �� � �� � �� (_"j , �v.U v—U G � I hereby aff�rm thar +he e is a construction le ding agency - SIGNEDTHIS D OP t� 4�. � for the performance of the.,work for which ih s perm 1 is c�NER oR � �if/�.'�7 . ��� OWNERS AGENi ��. . .. issued(Sec 3097,Civ.C.). . . .. .. . . qo�E� 6' ,�+ti i �a.<^ Y Yti . . Lender's-Name'.: . . . . . . � ._. . . . ..._. ..., :...: . , .. ;�. . . � .... .., .. ._,,. ... . .. . � Lender's Address �..».............,.........�..�..ow,....o.-�.,.�...<�. ..,.,.......a........,..�-..,..-.�.,....�,..,..«.�...a...,.,..................�...,...,.�,......�... � . . ,.�..,......u...�-�,.....,.,.�.._».d.,,�...o:�....,._..��.........�.._..•..w.,...-. . I certify ihat I ha�e read this application and sfate��fhat the � � � � above inFormation is correct.I agree to comply with oll CouNy . . � ordinances and Stote laws regulating Plvmbing and Sewers, . � . � � �-- - - � '� - � . ����and�here6y authorize represento�ives of this Co�ntylo enier ' �up abo�e-menToned propertyfarinspedion purposes. � - - . . . . o,�. � � q,.. � —83 � .� Signature of Permiffee Date . SEE REVERSE FOR EXPLANATCRY�L7IYP�GOAY9�' � �""�"`"` �"-�""'�'��'� �`� ���..�.����s, M.v� ��Fp��"�"��-�-� �~� �-������yR.•.. . . , � . . � �Y., ��_��<. �,..�.a..�,„.�+„�i,'.�,��e.�.� rK�;.z.�* _ i.,�. _ � � --�-- -- �,.. . .� . . . . ,:.,. ti+f5a�CTS3R's�QT"cS � :,r, ,,.._,. L�Fi�I'a�����J:�:���.'u'E��,fA�t�.'I��I�N. . _ .,. . ., . ,:., �___._-�.�.�� , . . . . . . . .� �:� v:n.��. •:.� .� .�.. ,..,.; ,. . � . . . - � - . ... . . ; ..:-. . �,r�'�O'd��S . .. o.+r iNseecroR�s�si�vaTu� � � � i;.cre�� -.fir ehzc x a 2 empe f a x� .,o erac:or's -- �- --.._ --- - � , . , : . .. � License 3w ur ti- f inp e.son��'ctfnsa 7031 5 New Nouse s_y,•ea . . � �u,^z� r.cL r, i r r.at.)� �1 y ,�: co.crcy : —__ . .— —__. � —...__:._,___._" .. ... �': .... .. . ' . . . Ni 4't �J�.�Y o '.t fe5%i CS G6£P 'HdlvL, CONI�ECTADJI ICNAt . . . . . ..... .,, �. . . ' BJIIDINGGRWbRK ... - .:�:'::� '� � ___ . ..., _ .. . . ..-- , "_ .- . . . .. .. �la T �]'Y� �, f} S�G'f iG Gf5 iU. , e : SEM�C TAnK.SeEv,Fir 51 - � � . �, .- . ..... ,. . .. -ars q i�,c t3-�: ¢yQ acnro .x cn p?r t:t to ffle a . .-. allo;o��F.ainF�[,� '. .. . :.�: '. � : - .. � �� � szgsse,?s,au..,.�n., tGrr Sn. .s�<�.te.,,_ee y^�..sunnE tc tbe --' • _ , ... ..... . . . � �— .__ '. c=55�o0�p oKrr�F�t.Q'_.� .' . .'_ . . _.... ,�-_-"`..' ,• .'�...... ,,:'..... -,. �.. . j.ro-.is:nrs nf the C .s e tar'.s,�,insn:sc Law(Cb�Qdsr 9 — . �. � . .. � :can:mcr.:z .-fn..s S��_tso?z�703G) f vsursiaa�3 of�the :� P1TEP:RE°AiR.SEWERO� -.. . .. .�.'�.� .. .'� ' . � � .:. : .. ' .:.'._._ ..... ..-..._... . ..:.. ..,x .....;. „ . . ..:. ....... . . . . �SEWAGEDISPOSA:SYSTEM'-' � � ' ' ' '�' � "�' }3u5 r.s�s5 4.d P:o�es.�4 x: r3lIPJ oY thdt �Je IDS E.Yen6pi . ..... . o '. . . • qSCONNECi PLUG f.ND � '.�. ..... . . '' � IJ T2(^OfYd 6. 6 W f 'JC.Q116� 2 .S^➢>�9 OA.1'�YL9� � P.&4NDONHOJSESEWER �� �__ . 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