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HomeMy WebLinkAbout1763A (10) _. ... . . .. . ... _....__ .... �.. . ._ . ,.. ,. . . .__...._ . _ WORKERS'COMPENSRTION��DECCARAYl0�1�"�� � � �. �. . � � �q I hereby aFfirm that I have a cer�ificate of tongent�to self �" insure,or a cerfificate of Workers'Compensation Insuronce,or ��-� ��6asc . � � .. , „ ._. . . .. .. GE BOB IREV.'B/81�. .,...... ... .. . .. ., . '.: . �,, ti ..`�k ...�.,t.w. ,.,.-.�:_a K,t ..: .. a certified copy Ihereof(Sec.3800,Lob C.} � � �PpLfC�ATIQ�V �dl���'�R�IA�T Pol cy No CompanY . . � __...,,......,.:.@s ._ . ... . . . . . .... _,.. ,. __ ..�. _. .,.. . . . . _. .. p g y�� "y� �c ..���y-a. � � ❑Ce tified copY�s hereby furnished. .. .. ... . . S�WErt " JEYYA�E LJ�J�d�AI ., .._.... .,.__ .,.... ,_ _.. . ..,. �� _.�.». ...,.� . .. .. ..... ... ..,. ._ _ ,_.,..�,�...�.-......�.«� ._ t[�Ce�ified capy is filed wirh rhe county building inspection COUNTYOF`!"Cj5�1l�t'r`�LESw�•����� gUlLDINGANDSAFETY .. ...'�departmem. .._ _,............__ ..: .. ..,: .... .. ;:��. � . _.., ., � Dore_ ' Appl cam FCR APPLICANT Tf5 FILL IN . M �-f!�� .CONNECTION DATA� � � " �CERTIFICATE OF EX�'MPYf��R�M��✓ORI�,�,kS�.s ,.,,••. . ., ,µ e�noiNG . .. .� .. ... .:.,� . . . _.-,.... ..., . � GOMPENS)(TION INSURr\NCE - AooREw Q J 51AilOh ��- / � DEPTH A � (7h s seetion need not be mmpfe7ed if the work involved by ihe i��q.iT� � ' � ,ewNr+oie ReFeqeNCE� '�-�� �� � i°PER.- pe�mit is for one hundred dollors($100)or less.) - � . . . � � � . , : ..•... . NEAREST . / •. 'Yv�OFNt�NFCTIbN ...... ��- I cerrify�rhai in tne-performance of the work for wh�ch rhis ceosssr. ieNcrnFaoM . � Qr � ��IS'��P . Y. CVRB..:. P.L. M.LiOP.I R: � - permit is issued,I shall not employ any person in any manner '��"-' �"" . ` �- ��� _-_ _ so as ro bemme sub"e�r to the Workers'Com ensafron Laws � . ... �c N6. � . tw� i P � . cwNez � ��P G� �� � �(f�, S co.innv.uo. ......{oe,No. ,.�`�.:f c�. - .:. .. .. ....; ..::: -� . -,— . .. . .. '.'. .- ' � � MAIL � y ' /� iRU�1NPFFMIINO ... ... 'ROPDPERMTNO .:�..� .. Do�e � Appl ca�t . .. nPoaess �v e.z�, i'!a �s i ._ . . , � _..,,_......�,.� �� ' ,+�: .�..•. . -. �- ��.��' � �y � AFFIDAVI� VJAIVER EASEMENi RECORD INSTR'NO DATE � NO71`CE��70 A�PLICANT�If, after mak+ng tha Certificote af � orv re�.No. �"d / - . Exemption,� you should become subject to the Workers' .�E�A. � � � � � . .'� -.'y� �'� � Compensation provisions of ihe Lobor mde,you must torthwith oesceiarion . ,.orrvo. ��� � � ' ' � .. HWY.ORST.�WIDENING" �� � �'- .. cdmply with such provisions or ihis permit sholl be deemed r�1 U � � --�-�--�� ��--�-� - � _:; ..... �eyOked. .. . ..., . :..., 6lOCK iRACT J [ / � . StAiE ENCROACHMENT . ,... . . .. .. . _" , ..� LICENSED t.`ONt�A.C�OFFS'�ECC�X1k�CYYO�Y6....:.=r.+-.....v-�..,�_.:,::y� NO:OF BLDGS �... ....�.....' ..... PE4MIT NO. _ — ,.; ....._ . ...�. e�..��- I hereby affam that I am licensed under provisions of Chopter SREOFiOT (�f�}d Q Nqv(�u.oT ... � UFE OF y . � ��9��(commencing with Section 7000)of Division 3 of�the Busi- �. guim�Ncs � n sa �,5° G' CHC+ cHnRGEs ���- ness`6'nd�Professions Code,and my hcense is m full force and _ � � � .. � � - ���s ' e{feCt. CONTRACiCR G y�y.' CONNER�ON CHARGE FEE : . . , ., _ . ..,...._.. Lrcense�Numbar � � � L�c.Class� .. ._... � ,P aeimeuaseMeNi Fee �� � � ��' � � � ,, . ..;.. . .,, ADDRESS , CO�f/aC10I � ,OtliC �� C'.TY -h 2 TE�. .J 7 Lj s[_ ��STRICT NO. GR UP MAP PROCESSED BY� . ..__. � �. . .... : ...: . .. ... ... . -� � ❑ I am exem t unde Sec . of the L.A.Co. srnTe� �] }^� /^' q uc. �^ � �,.�'-��y �K/✓� r C P , : ^ IICENSE NO. / ✓ J /^� C1A55 � / , ' .�,.. � -. ,:,_ , ..:�. a � . ' '" No. DESCRIPTION OF WORK ��_FEE P�umbingCodeand/o Sec. ��� ofihe . �, �.� ,�• � �-��� �������� Frrvni � . - .: . �' ,.. HOJSE�EWER CONUECTING TO� . . . DaTE �� f-j� VALIDATION ..6.&P.Code for�ihe followtng reason � v:,?uc SE�a2 . , .. ✓✓ � .. -.�........ ......� �� �"'. SEPTIC TANK,SFEiAGE Pi'OR � � G:?5 AND:OR ORAINFIEID � � ' FINAL .. , ._..:_�., �at9 YOUSE SEwER COtiNECiING TO � � , gY ',. �,'., ., � .. "'....:. i ...- ...'��:: PNiVATE-DISPOcAL 5:'STEM- � � � $I JnOtU�E ����� �-��-- .�«=+.•�' CONNEC7.4�DI ICNAI BIDG-.OR '�� , � �" OWNER-BUILDER DECLARATION �� ""`�� wozk ro Ho�sc�ewea . ,.. � - ' � GVERFLO'N SEEV GE FiT,DRAINFIEID� � ..,. , I hereby affirm thai I am exemptfrom the Contracto's License .__,,,. exrN cessaoai oavu.�i�,�MnrvHoie �- � - - low for the foliowing reoson(Secion 7031.5,Buisneu�dnd Pro n�Tea,aeFnle c;it qaoNooN House� . ... . .. . . '' feS5iOn5 COlIEJ: . . , _ SC�NER UP.�15POSAL SYS7EM { � �. ❑I,as owner of ihe properiy,or my employees with wages as .- � � � �z� J j . _ .� iheir sole compensation,will do the wqrk and ihe shuciure - �;�, o e o j Q is��not intended o�offered for gcle(Section 7044;Business - � ��`�� . �.�� ,. • ' ❑nd Professions Code). �WNER'S Permit s �r ,h'�° - . TOTAL PEE ; ,� �7 i'.6:� ❑�,as owner of!he property,am exclus�vely comratting with AUTHORlZAT1�N � � '� - licensed COnffaC10r5 f0 COnSffuC1 ff1C p�ojeCi($ecfiOn 7�4d, I HAVE��i iMiS DATE A,CONTRACT WITF-T:IE NEREIN Ni'ME�tONi 4CiOR iC ^ � ° r �.�?�;J � � Business and Profesvons Code) CONNECT iHE FBOVE DESCRi9EISFFYSTINGDWF.C((w"Tb TNE4U$LIC SE4MFF.''� - � �� CdNSTRiJ�CTIOIJ`LENDING AGEf3CY '�'��� � � � � �� �` �� (_�'j �v.`v'v—U G ,: � I hereby aff�rm thar +he e is a <onstruction le ding agency - SIGNEDTHIS D OP�_ 4�. , � for the performance of the,,work for which ih s permil is c�NE°OR g,,�f� . . issued(Sec 3097,Civ.�C.). � � owneeSr+Ge/v�� �L4/L'_1r .,. . .. ... . ' . .. .. .. . � , .. . ADDRESS b •r+N i la��t" Y C� Lender's Name�.. .... . . .....`. ." :...: � �� . ;�. . . � �- .., .. ._,,. . . . .. . � lender'sAddress �..»..............,.,,.........�...a�.,..:.o....�.,..a.��-.�.....,,..�....e..,.-..,..�-..,..,.�.,.��a..,....�..�...-�.-.,...�.....a......,...r..,...,.....�... � . . ,..�..,......u...�-�......,.,.�.�».d.,».o:,....,.-..��,..»....�.._....,...,.,.-. . I certify ihat I ha�e read this application and s�ate��fhat the � � � � above infermaJion is correct.I agree to comply with oll County . . � ordinances and Stote laws.regulating Plvmbing and Sewers, . � . � � �-- - - � '� - � . �and�here6y authorize represento�ives of this Co�ntylo enier ' �up abo�e-m`ent�oned property for inspedion purposes. � - - . . , . o.-. (..�' � �',� � —�53 � Mv.� �.�.......,.�..�..._�.:.,� �..��..,....... � .� Signature of Permiffee Date . SEE REVERSE FOR EXPLANATORY�L7IYP�GOAY9�' � ���"�"`"` �"-""'�'��'� �`� ���..�.����s�� . . . , . � � ��aY.. ��_��z �,..�.a..�,„.�+„�.i.'.�,u�e.�crc r.��;..�,� _ i.,�r _ � � --�-- -- �,.. . .� . . . . ,:.,. 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:REPAiR.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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