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1644A (9)
� �msure bar o c�er�ef aareCF7dA�Y�`5A7tdhf DfC1,4R�T101� � � �.. �r ,, `. �"°�. �'_" ,"`. .� ��� :" y . . _ . � �1� r - arz-000s uvv�s er - � y � " have a cerh�cate of„coRsent Yo�sel�,� _ �. . _ . ^^` '76A642D � of Wqrkers'Compensation Insura�ce or �E�a � ' ' � � - .. s ��Ce'ftrf ed co rfi sr herg6esf�3800,Lab C) - . �,pPY � � � ��.,:,,.�-.,� A��LIC1�`fi�ON�FOIt�P`ERI�AIT ..Pol�c NE��CompanY f.r°LSlO . �s ,.,:,. , y ; . . .�. .. . . " ' � �'n WER SEWAGE D15POSAL � PY Y hed . ' . . ., .. � . .. . , . .. � t...� ..: ,. _ : - . - - ._ . . ,,.�Certified capy sfiled wcth 1 co nty buildmg inspection C�1UN'��IOFLCS5�9NGEi,E3 BUII,fiING�4NDSAFETY _ � + depa t ent � ��. �- .. . . . , ��.. , � . . . `Dme/_��!���Appl�oan ����s � FOR APPLICa1hIT TO Flll IN � . CONNECTION DATA '�` �,. ��.�, 71FICAiE OF�XEMPTION FROM WQRI�S . ,,; suicb�NG stATiaN oEmH - "�' C6�ii('ENSAT�OFl"th"�$b1�A�C� aooRess �/J'�C� f"7 . z. ..:, . ��Th s section need nof�bQ completed �'rhe wpik rnvolved�y the � - � _nN,Ntio�e ReFEReNc¢ � / °E `,;pe�mit.is for one hundred doflars(y1p0)or less) . �aAu*v- � �7 towEe NEAREST� � �� � TYPEOf,CQNNECt(ON- ' � LENGTH�kR�O'M �'`�' , .. .. �.., . . . ,,, .. .....-.. .+n_ '^��.,.xa' ,- I cert fy th�at n the.�aerformance�ot tfie woik fm vehic{i�this crzo55 si: v CURe � ��-- M['o v.L:� 1 �j'''pe?m f s iss�ed I shall not emplpy any person m any manner -� - ��- � �,s�,as ro become sub�ect to the Workers Compensahon Laws ._ owNER.� i CO IMG NO.. _JOB No �� /.% � ,',: . _,._.. � - - . � � � � .F �y ,.�, .�� k$� .��ti4'r''��$„�f �- MAIL � �' TRUNK PEF/�IT NO �- ROAD PERP(li NO��" . Dafe�.,,.,Applimnt : nD�RE55 � � � ` � -� „ ri,,,. � � ..; ' ° � ' >/ �y�p y' ` � AFFI�AViT WAIVER EASEMENT RECORD INS1R NO' DATE -'� � {�O�f� �O ��t7sfio Id�be�omg 5�6�ect��s C'e�tificate of ._; cm � � � Te�.�nO �"Y ��7 Z 4 � . pµ.. Y ., �9 :o the W4rkers . tEGA�� -� � . . .. _. .. . .,., . .. .. ....' . `":"`, _� ��om ensatio� rovisrons of tFia La6or code, au must fonhwiib.. . ; oesGairiiory Cot'Ho" Hwr oe sT,u�nqeNiNc ","cbmply with such�provisions or.this permii shall be,deemed - - ' ` ' �" ""' ''� � � �'" "�- . ���' - 'Y'g;VOk2CI . .. .. � BtOCK� TRACT �. - PERMIT ry0 OACH ENT . . .., . ... `�� �.._. � 9� ) �}ONof rhe�� ; No or�o�s .- ' . , .. fJCEf�5E15'CONTI�q�7CtR5 DECL`A�R sizepF ior Now oN ioT � � "I hereby affvm fhat I pm 1 censed,`_unaer prov apter use of' ��' '� `"- � � r �� � ... �,., ,...,-�. ....... �9 commentin w th$e<hon 70p0 of Drvisid ,.6usi ,, ewtDiNGs � CNbacES�=� �-nesS and Professions Code and my Iicense is m ful�foree and -� � -- ' �-'-"- �- "�e{feCt �. ".� �, , . � .� CONTRACTOR . . . CONNcCT10N'.CH,A,�2GE FEE __ r -.' LicenseNumbeK.�Pl/Z3 ��c.CJass, �'=' � �' nooaEss • -^ aeiMsuRseMe Fee . �_ �" � r� ' ' �I5IRfCT NO.. GROUP � MAp'�. PROCESSED BY... O .. ' �Cq�fIhRC10f�,;��d���d��Daf2 � ��: . CITY ..'� TFl NO. V�- C �L � - ' � '.. SiATE � . .. . LIC x. ... a 4,_�r_❑I am exempt underSe< �, of the L A Co . uCeN ��� . - �� ctnss . ��. -� -� � ` W. _ ' � ,�. A_ .`_ . ..t.. '^' �� ,. ... � � Plum mgCodeand�orSec. �� � ofi�ie No. pFSCRIGT,t6NOFWO,Rf�;� FEE" ""'" "" "'" `� FNA�� �, � . - �t7- i . � � g p�eucsew� ar° , ,.a �, . . .w- onr� �„m�.�'���: . VALIDATION � a s�. .,< HOUBESF`NFRZKjNYJE[T�N :��� B &P-C'o forih followin �reason �__,,,_,,.^_ ' � �' . - � � � �-� ,y, - � $EGT(CTHNR SEEFAGE PlTOR `, ' . . . . CIT$ANDT(.tR 6kQIt�Fl�CD .. . fINAI, �. . -4� " � ' F�9US�SEWfk CCNVNECi`(NG 70.,, ,.' .• . . BY — . : .. C -� PRIVATE D SC05A'L SVSTEFX �� $gl'141 . CONN CT ADDITIONA4�La".a OR " - ...�.. . � .�....-. ..�.. ......�.. ��I hereb aff�rm rhat'T`om exem�t'E�ARF�Tr4 � �+°R�'�'oHoysFsewea ��� . '� OWN�R Bl11LDE D � x� � . O ERfLbW SE�PAGENT D�/+�M1{FIEtO � ""'" � . � ,r -� Law for the folfowin reason $ectrom J�le�ontcatlor'SlicenSe,,, �„ EXiN cE55voOL�oRh4El� hFHOLE �� . . �� �(�(�� � . Y P g` `( on 7i731'5,Bu sneas and Pro 'atiFx,keaai�ort agkraoota KOUSE " � . -� � � � - �' f636�Ol15 CgC�Bs.� '�' . SEWER OR DISPO5A.SY$TEM , � ' .. ' :. :.., . . .�� . ,. , .�.. ... .; .. ' . ��4�.o .� �! . o,a � ,��; ❑ I,as owner of the�property,or�my employees with wages as � � . "' ' thev sole c4mpensatiory will�do the work�pnd ihe siructure ,.�. ' - � - ���V -��" � . � � is not intended or offered for sale(Section 7044,B�siness, �� . � a •�'2�7�5� � and Prp�ess ons Code �� � �� �� OWNE�'S PB�[Cl�t , . E �1� ..`�"a`G%' � a.. � AUTHORIZATION � ,�, '� a "�7,5 p o � ❑I,as owner of the peoperty qm exclusively cont aGting with . �TO1�AL FE�, �� „�' �. licensed confracio�rs to cyastrucl ing pro�ecf j5ed on'7Cfd4 ,nAVE At rros on�a coNraaa wirH rne�aein�`wt�r�ntv coNtrzAa u To I 0;2�6�'-8 i - � �� � ', SIGNEO TRE ABOVE_QE�SCRIBFO EXISTING DNELUhG TO l�i°c`�U6ll�'SEVJER'�'` ,. ., . O�I.YG AGENCY � ,.. .,---'-'---'��1—},_x- . ,., . _ . . . ,��I here���aff'�����heTO�a�°for�wh c�h�this�per� � �TH7�5 ' DAY i�'� 19 � �.. y EITCy . .. . . .. . .. .. . ... .. . ,' for ihe perforrt�ance.of the work„ mr s owNER�a ti{ �'� ' - - _ . • issued(Sec 3047 C .C) � . �' : '. .-t � . AqORESS - :''Ce der s fJame � . '. ' .� .., , � ' : y: :, � -�. � �: �� ; �; a�'+:�v�� � . . . . . . .. '� Le der s Address � .;r ,•�w, , „ ,�v., , �,_. . . _,,,�.. �,._. �»�,. .�..�ae r L ..-,.-t., ��.ay 7,. �.. � ,... . � . , _ ,.;.>. . .a,..,< . �. . > . _,. .:�.. t�..ri.�.,.�v .;.A�:;. »�, .. .,-�__: ,a ;: .:...�_ ._ �.,,_ ,»r,.,.., .� 1 cer tliat I have��'read this application'aroc]state thqi ibe , _ , , � ., . ��'' -._ -� :;�p ve�in rmation is rtorrect.1 ogree�to.comply wrth alf Epunty-��� �� � � � � � -� �� � � - � � �� �- �� �� ''"' rdinanc s�and State.laws�regulahng Plumbmg and Sewers,"�" -�' - �'"' �' � � ` � � � .; . .. : . . . . . . .,'.�` and her by authorize reprc.sentatives af thi3�County io':en'ter ' . .. . ".. . .":,�. "-. .` . � "`.'.`... .. . ,..'. . . " ."'. .�... .`" , . """.' .. .". . :. upon t e above�-m� �oned� ��ity for inspacho� urpOs ' �.° , `:�'� ,,� ".'�" � ::`. . �. :�` ..". � .� .'..:. . . . ... . .. . '�" Signiitureo PerrrjiJtee ' D,tir ���- ��.� SEEREVERSEFOR:EXPLA�JATORY„LANGUXG,E„_,_, , - . - "� �,.. , �� a H ._ ; , , ..> ; ��y ��r � _ _ __..: ; _ _. = x +, � ,� •N�1S��cxB�°s��7� ,. �'�10i£+IZ}3�?ILT7E�TD�C4.A�'�36?N , _ _�,. ,. .. .. .,u. _ -.� ���P�RO�Al.S�. .onre� . .iusvEcfoassicNnruRe�.. �.. . .:.� � �.Iherebyaffirraathar�daerieae�spd�frovazhef:�eeac2os's . �� � � . .� , ���..�_��',.::.�.�� . . ..;� .:...3�, �:;::� ,. x�, . . :.�.-fi,acenae.Gam far t6e-fblPowing'taa�c�n f§ec�daza 763�.5,�:.�. . .. NEW HOUSESEWER"�- .... . . , . �..._ . ... _,..,. .. ._ , ,,,.. .$rYsJ .ttad P�afess4osas �odeJ:�eSny cs irr coun*y. CONNEC APOITIONAL � . � .:.: ��:�' . , :.._ . ��...� � . � ... � . .. ��.wbicPr re vures,a ¢r+ndt ta cows,truct,��ad�r,.�ar,a � 9UILDING OR WORK ' �-�I..� -.-: ., ^ � .� , . .� . '.��� ...'.�;aTem.olzsds,Qur i2puusr eri���strsactur�e,prBar sa�isa.u.ssadnce,�� �. SEPTICTAPJK SEEA.FIT(5) . �.�` . ... -. . . , p y . . � rwororzoani�u�tc. _.: ::: � � - ' .� . � , ...:. .. .. _ .,..:..,; , _. .:,�,. � - - . � - . ... 'aka�regairex t�ie.:�,aP,pd,icari2 for asesb zroerer.a8�to.$s/e�a . � _ ...-_: .... � .. ': � CeSsEooc fl �oavweu❑ . .... , .� ... ����., ..,,.-----_.__.:� ' ' .:,;. .a .:�-. ., ;, . ..�.�signed'staternen3 ahaa bs is dfciused pursuawt ao &be :.. . . `� . � . .�-- : �� }rovastions iif EAe CaazgracEos's Lice�se Lxu�/Cfrapt¢v 9� .__:�.:._" ... �. . . ... ��.::. .... u�-�- ./cormri�r�cEng sustk*�Ses2doas 7b001`-6f Dir�i.rim�3 of S�e�. � AI,FER,qEFAIR SfYdER OR , � �,^ -- � 5ewa�e oisrosnt sYSt�ea - � . ..�.:; .°;. ..� ., ,�.. ..�arsio�ess arid Prof�sssons CodeJ oo�$bct dre����as e.�'esn i pYSC97VNECfPIUG"RND � . . .-� .�" ��.:� -,, :. ..� "' .. �.. :. �.., . � .. . ... .. �.� nanNno�f HousE�sew¢a � -..._..._ _�__.__,.__�:.__�.:.......� .'�sSsrajroen amd eb�b¢su fcti°the�Sdeged�mp�€an.riay � . . �. 6n¢�eFn s�PrierflNKs❑ . .� -. .. .. ���� �� � .. ��vdodseCioo�oJSeefson7b�1:3Lyun.Yg?131(casatfor�:psmadP: . SEEP.PI s❑ cessaoots Cl �. ..% � ,��_, � -� . .sud+jer�tbe.appdkant 8o a civid�7emcc8ty of not ieaore s[rmn�' '� - � � .? + ':�� �_��-��� ¢Ac�bux�red dnllars/.�5t10%e ..... ,� .. __ .. . -�{: t ;'` � � .,:..s -� M�---- �...C31,as xh�ocmet o£ilae�ysropaz2q:veYfl'da tbe-�wosk,ar'it�,. . ,�.:;. ,... ..%.. .. . . '.. ,_ .`. �_... ...., ..,!�-.._ __' .�:.:,§'. , , , `._. ... .,. .. , .„ �` :,.. ,��. " �-4he satat¢ure is m4e Inx2ati�dor te5#feed for`-5a��. - �,. . . „`;`' .,.� .;'' ,�-:.. . � -` ,�`: .�;�:�. ' .�.�YSes 7A44;.Busrners-aesd P'roftrarions Co�;'��7'be Casa-.�: .... t. -.�.. ..�. .-�....: . .�:..__. ,.�,,: ,.: _. � �,, ,, �.�.. :.""3r'acC�r°s"�Yire�sase�avi`does r.at`aPAdy ao ar'�awner asf-, . . ,.� ,,. ': :. -:,., _ : 1 .��.:.'�..c.., . `-e . ,. v �thereora ttnd wPio edoes .. � ;..::.� . . . :. .. � ..�.. '�_-, , . . . �.�� ;.�mchemo��Fidrea'rc�°fji`��otida°�,.�mtsiteb`f��mp�overrsents���.. . 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