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HomeMy WebLinkAbout1651A .� �a.-r,�c+,� '��*�.� ��« -.�w...��+ `saK ��. ` . �- WORfCERS COMPEfVSATTON�ECL�Ri4TION �� �� ���� � � ' -� *'j� �y � � � r�,r �:_ -� . ,,.: .. � :: - *� ua rz 0002,DPw.si§� � ,.L�CL � I hereb a�f m thaf, Fave a ce�tificaie o consenl to"'se�l�"`��+'�" '" � '`: " . " �� � v l w M;.� .���w �ac.a<za . � �- �_:. insu e or a�certifiwte gf Wor�Cer,�,�„�nsahon�nsura,nce or � �aoe � � � � ' �pterhfiedcopythereof�(Sec �800,.�ab� -� � .� APPLICe4TI�N.�,FOR P�RNCIT,_� ,,.. �. Policy Klo�f Company .. �_ : (�s . �±��y y� �-�!�( -e +� . _ . . ... .�[�Cert�,fi,ed copy is tieFeby furnishedv f .,.�� .�, �� � . , ..- �SGYY�f( �YYI1C7c D�Sp�`J�„L._ � .... _ ��Certified copy�s filed with the couroy buil,dmg inspec�ion � CCRINTY�F LQS AP/Ci�CES BUILOINCa AI,Vr,D$�FE'fY � dePartment ' � : . . . �;. . - . .,, .., .. ,, .. � �+�e:- �ate/ °2 Rpplicant � FOR/APPLICAN9T TO,FILL,I�1 � �?.r�C7 CCIfl.NECTION'�ATA �,�..az ....,. �. . �C�k1'I��ICAT�DF EX'� pT�I�N Fk�N�W�,,�R�f�tRS evuowy:. ' � sTnrioN �f/ oea�N•�� „.s- !� � � � CtjAlip�M11�5��Z51�I1�°1�Uk�i.y1�CE�=� "�°' nonaess ��. '- ... _ .. �x ,(Th�s section nee�np,t,�'e compleied,�i the wqpc.inv,o�ec)�y the�� �.�� � '��. MnNHo�e keeeReNce y-�� R J IOCALRY �:pATtP11�IS f0f OI1C�tUf1C�F,Ed yO�IQf9($T�j Of�C58� _-r �.*+n^Y^^+ceKre�,.++^':'�o��? . TYPE OF�CONNECTItJ1aS�;,�, ' �"� �NGTMFRdR�' � NEna�sr„ .:r-. . . . �,�""`..,� .,: . . � ., , ,.-.�.. .� ,.�. . .,.-�., ,. „. n ��I cerafy tho[in thz performance�n�the work for,whic,t�,this„ „ caosssr:. / � �� � r cuFe � 4L :. Mt ioPt ,,. .�permrt is tssued I shqll, ot employ any person in any mnnner : ..:� , ��.,-� - � � �" a c[No G����°� ' �;so as to becorne svb�ect to rhe Workqrs �ompensaM1on 4aws. ;�. oy�(tiEa'.. � � co iMP No � �oe No 6 -�- ,a-mx t s ; . ., , . _ .., �..„:�. ... . .�,,.. ,_ .£ # :a. ; :. �'M�l y �'� TRUNKPERMITIJO _ �. ROApPERMITNO� . � �. ._ �- �+ AD�R65S'..r.P� . . �Date � Appl cant � � r r�qvi Me eco _....�. -� ^""' "'"'" � AFF T ��WAIVER FASE NT p. RD INSTR NO. � DAIE�-"�`� .-,...a . .. .. : .,, _. . . . . ..., . . . " '1:�(}TICE TO;�PPC�CfCN� If, after�makmg"tti.is Certif',,cqfe bf ,' tn � ' ��::ry �� " �'' � ;Exe`m'phon�-yoo shov:ld becpme� sub�ect.'to` ihQLL_Workers ,.,,,.., ��cai' � " _ `� - � � - �.'_Comperrsption provi's�ons of,ihe Lgbpr code,you must foriFi,wnh ,�;: oesce�6rioN 607 Na' • � � . � ��� � ����'� � Hwv.oRs*w�oeNirvc ' �'C3mply with such prov sions or.this permit;holl,be_deemec{ ,�.. - ' ' """"'" / ' � �� . fC�'9kBC� : '� 640CK _ iRACT !, . . STATE ENCROACHMENT " `�' - �.� �..�.: ! I . - FJ�OF BL7G5 . - FERMiT NO, .... �LICENSEd CQ�7'�2`7�C7dR dECLd 70N � -� � ��� .� �k�ok.� ,< SIZE OF�OT NOW ON LO�, `y ���(herebp af�i m that j�am licens�d�nde provis�ons of C�haprer uses� ' ""�""`�"�°'�'�' "" � �' �� �� . . .. , - . ,,.:�_ .,,, .��:ar.,..� � . : : �,,9`(to+`nrrien'cing w�qh.S�efhon_7A60)of Drvi"sion 3 of,th,�Busi...,. ' euiipiNc5 ....._� afaeces':' ." . � . �%�ne'ss and PCofession�;�qde,and my license is-in full for�and .,._. - -�-� � ' -�" . e'j "���p�_ , � • .�oNNecrioN cynR�eFee � � �� $ t.bx�udrvu �. �effect _ � '(f �y : � �� �� oN�anctoe �� REIMBURSEMENT F E �µ� �� Q' "�)ce 5er1urT7'ber +� `�'��✓ Li[.�Iass�,,,s ro �� AO�RE55� T � j � �. � �" '�^ n . P15TRICTNO, GROUP ' MAP ... 6ROCESSED9Y.-'. (J .,��C'�ontrac�`o � Oate �� �- �� crtv � iEt ho -� .�:.� .:�. � :.� ^. � .�;.. '. srnr �� ' '.: .' uc. _. ,;� ( .w ' �,:�. ',Q I am exempt u der$ec � �. of the L A�CO ; uceN No �� � � cta55 - ' ��, ��.- � . �.., d--� � (� � _ . .. � y,.,.: r: .r �:, r ." � Nb �- �DESCRIP7VbN0�`WORK� ��': r�++�;.,.,.,�!y�*..w Fiun . . . . . V .�. � PI�m6ing C.'od �nd%or Sec of ihe � , ,: „-_.,,� � � � a <, � .„• NousE seweR°cD'NNECrfMc to� 1 �,p oare 1'Q.�i��y� VALIDATtON ` B yP.,-� defortefollowm �eason. ., ?ueucsewea.,; , vy � . -"'�' -�yy,. •. Y r-., 9 . . . . •^ �-. SEPiICTANK SEEPAGEpi70R.,.. �_ �,. ••...• FINAL .. . .� '.,..... �.- � � PRS ANp/Ok DRAif•1FlELC - �� � - "� .... —��. a'.. . .: ��.�HOl15E"SEWER CQNNECI9'nl,G T . «.�•,� �,,• ,�. .BV d'n �� �.. . . �: '. � �" � � .PRIVnTE�DSPOSA'YS 4"`"" "" ' `.'"` EJ\.,J•' -�� $19nafUfe . , 4 �� �. � C�IJ�EGTPbDITIQNAI BL�G�6k.. .�+..�ssW ... _..... ...........,.,..... ......_._�,.»_. :.....,.._.,..,..._......... � '"' ' OWNER$U1,�bER 6ECLARATIQ�;p, �' � �� -womc70HW5e�stwec "' `�� ' ' � . , � .,.,.,u., y.oy,yv..,�: ,yp�,j,s.a,n..;�m�.ua�,nn , r OVERFIOW SEEPAGE PI',D INFIELO ."""' . . -I f10f0bY af{Ift71 ihPi r pM AXBIiI�}�1 frORl ihE COn1�aC10I�S,LIC@RS@ ,,,,,,,,;,� -E%TN,CESS OC;QRyWELL NJ+NHOLE -�. � ' � -�:,L`aw for,the 4o,llowirrg�,reason(Sectort'7031 5,Buisnvss and��Pro '' ���qtcEa eEvn�k oe`nantip�N HouS� ""'""""'""' . � - � �- sewexoaorseosAEs�st�rn� z i 6'�,�:1 P, '.fessions Code)i _ _ .�... . ., .. . . .. ,... , r.._.. ,.,w.... �. . - .._. .:,. ,.,,_,.�:;. . �..._ ....,: .�.. .r.... :,.. _ � . _, ... . , , .,.�: �.r ❑I as ownar of the�property,ormy employees with wages as . � � . . � .�e �,�n �;.F,�� , .. . r iheir so�e mmpePsah�n w�I-do the ork-pnd the struc)ure � �. "� ���� ��LLFa.'�s�� � . '- s not�-ntended o�„soffered for s e Sezfian 7074 B,o;jne45„, -� Pefrt)rt � $ ��°r � ��r�`7�� � � and Professions Code) � � ' ' 4WNER 5 ^� ow Q I as owner of the property am extluswely contract�ng.w th ' AUTHOR�ZATION TOTAL FEE , "� �' s m B 2'],$("}z (icens,e,d contractors to cDnsiruct the projecr(SecNon 7d44, �HAvp�nr Ty�S onrE A coNiRACT VVIrH rHe H€R�EM�NnAhEU C"b,t�t'RaCOR rq�, � � BUS nf55 aT(�pf0'�0$5 Pn�o�O� �� �� CONNKTiH�A&��1E,�E'�CR�BED EXSTIN7,"JW�9ci.ING�TQT}1F f�U6l�lC.5�,E4,4E�R �,�. . , ' ff,'2 6���� � - � '.�. CONSTR�1C71bLN 4'EN�I�1G AGENCY` ... �. � ����. . v . "'�.�- � ' SIGN�D'THIS DA�'�OF 19 � � . ' ; . ,,. ,r . „,�.,� : .I�hereby a�fi m th`at;�ere'Ys a construcTc�n�le,�d ng agency . .- . n..—"' . . .. � - . . . . . . . "for th,e performance_of ihe work,for_whicfi h's ermtt is � owu�a�oa - . .. . � ....I. P OWNERS.ACzENY ' �•-•-- .'f�ssued(Sec, 3097 Civ..C) - � . �� � �-�� ��-• � �� ,. � .. . , < nooaess . � kA_Lender s Name � �, . sw+�.rs .... . _.�_,-....,. w.,. ,... ,.. .... .,. .. ,,.�, .._._.. . ..._. .. ..,... � s�w' zs ,� � �; � `�' ;c- �' ,� cy��.�,'� �...�. _ -.. , ��Lender s Addr�essw, - .��.n�- .,,n*,:�„�, ," „�.��,,,,�a.=.c*=,,.;x � «;�,w�«;� . . '. I eitify�t�hat I have read�fhis app�icafron ond sta1e i�af e - ; . �`�""""""""""�'"'""`""` '""' '" '.." ����a6o e mformat o�is cor ecL I agCee to comp�ly with oll G9unty i _ � ordi ances,and�tate Ia s,regulating Plum4i g and Sewers � ' ' � V d hereby au r ze.rapr .taf'ives of thas`Cou'ny""tq:enre� - `%� '." `. ": ,`. °. . ."_= ,-, , . '. ' �.. . an , ;.-,�. . ... _ , �. . .. . p n the ab e nfio p �perty for inspeclion p�rposes � �� �. - -,r,.-e ��. .� . . . .. : _ � � �. �� '... , "' "„"„" .."",..:""""'SEE"REVEik56FbREXPCAN TORYlANGl1AG � � SigndtureofermifYee '„ � D,ate.. . . . ..!4.�_...u...,,-,..,.....�a.,� .. ,.._ ..... .....�....,....„....�...,.w.�..,,.r,�..,._....�..__... __....._. _......_._._:.�.... .........._.. , ,_� , . ., . . , .� .�_ . . �., . �. ��. , : - ,..-et�s�, - �..s n.ag � -L,P ' .. , . , r ,,:,... „ ,, � �.�.,� ; � ,: ,< . ._ ,._ ,,,a. Q , � , , _ . ., ,. �. n , . �x � , � . . ,t � r'h � c w�`���. 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