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HomeMy WebLinkAbout1645A (9) -. r r .3�e s'ec �t»��'r � : - �.�` ,, � .-;�-�F .; . �. - ,.,.. i� "j '.'":,-i a, � WORKERS�COMPEN$AYfQN QECLARATION �� r � "�` ` • A ' f/i-�, � � `. _ , . . .„ Y�.. ... # '. .91 0002�PW 3 8� , " F Y{ ��.I hereby affirm t(tqt I�have a cefhficofe o�con�an�,tp,geli, _ „, 7aava2o� � � - �� �:insore or 8 cert fitate-of Wprke s'�Compensbtion Ins'urance,or � - �� � -- ^�,. CE BOB . .,. . . � . : .'a cerhfied_.,cr,o�py ihereoY(Sec 3800,Lab C.) . ... . ' .. .�.. �PPLI��iTIQI�i�-�FCSR�P�ERNIIT . . . .. . . ��F�olicy�a��„�Company �� J"'.t'�?�.�'z`ieCf� .. �s .. � .. � � ,.. . _ .—. ._..., �,�. � _.e,_ y4 _�._ w__ _ ... ��_ __W o_ ,.�. . _� �� _.� ..�,�fWER = SEV17r4GE DISP�SAL� _ �d Cert f'e�cqpy is hereby furmsh .. �� .. � � .� � �. . �'.�Cert fied topy is f[led witF e co nty bu�lding nspeci on � � GOU1!ITX OP CO�AWGEI,ES � � BUIi�DING AWD SI�FE?Y, �� de art e�f � � � � . - �� ''Date Appl cant ` ��2'_�L`���� POR APPIICANT TO Ffll t,N .,� GONNECTION D/�TA , �� ; . ,..�__. ��- CE IFlCATE OF EXEMPTIQN FROM WORKERS aunroin� `� � -" �� s^�♦� STATIDN � DEPTH � £ ;, C�IN'�EN5,4TY0�fN5`I7khT5'CE noou�55 f,JW �f�' � _ — �-�(Th s section need noi�e compieted�f ihe wo�C nval eti liy the �a�Li1V . rvwNr+oie ReFeRervc[ �/" - �� �� „ ,„ptrrtt 1 is for one hundred dOila s($70�)or IeSs) � - . ..eaP.�.- ^w^ r NEAREST� TVPE OK NNECTION' � ��� [�.(GTH FRrvOM �,i� �� "INcert fy tliot n the perfo�mance o�the wo��for w�i�cFi ih s ce655 sr. � �y, cuea P.� -� M i ro vc� / � .,. ��"pe'rMit is'ssued I shqil not empl6y any person in ony mdnne, �- � .�.--�,• ���" , :�� . `�'sa as ro become sub�ect�o ihe Workers Com�ensat on Cqws. owNes P' co iMc No�:. �.poeNo. �� � �� � � �* -�Ddie � �� A� ICtlnf�� � �� " ADtlRF55 � . k �TRUNKPER/.11T�i.p � ROADPERNGTNO.'' „ "" ,,� pR +.«-.+�W ...�...� "�' "' '� " "" ��-- "".�"�- AfFIDAVIT��WANFR EASEMENT RECORD INSiR.NO. DATE� � -��NOTVCE"7�AN7 If after'��making rFiis Ce hficore o�' arv '' �� tec-no � "'` � �Exemption; yo� should k7ecame. subject {o ihe'Workefs' � . _ LEGAC� .. , .:, .�.-qr.,�, ,« ,:.: «.... .y..... .,-,-_,_.. ��ompertsaton pro s ons of 7he Lpbor code yOV tilU5t{Of1hw11�1 � DESCRIPTfQN CO`f NO ` . HWY ORST-WIOENING - ' •�c'd'ntpiy wirh svch provis ans or thrs perm r Shali be deemed � �� � - � 'YE'VOItE� � � � � BLOCK'� TRACT' SYATE,EMCRbACHMfNT ` ' ' � ��' " '� ��:�ICEN$�D CONJ�A'�CTOT2�'O�CL,�41�1CTi�p�� � rvo op e�P�s, a�RMtt No � - � �. yz, M..�; -� SIZEOFIAT ` NOW ON l0T �7 �f I�}i�re�y affirm thai��am I censed�untJer prours pns o�C�iapter - ��oF�- - ",� � �j �'� 7 . ',"� cqmme rofess ons C'ode,and my license�s'n 3 of rhe Bus_ , � '� gw�pinGs ;- ._- f '� � �naoes` ' � � 9ect�on 7000 of�i is'ro -nc'ss and p cing ith " { '�..in fuli forc@.and - - e�fCCf �� � , - � roN�TRAGTOR � CONNE�TION.�HAR6EfEE. . ..... .... . .. . � .a;L cQnae Nymb = !�1 .Lia Class � .,. � �� _� ApoqEu_- . , ' rzeiMeURSeM NT�e , �� ����COf11{p�}O��� , .. Dd7C •'" � ... : '. .�..,,, •.'� DISTRI[T IJO.� .6FOUF�� MAF -.' .:., PROCESSEQ B1'. '- -' U ,�+�-%-, .. . ._ � . CIN. � TEL NO . BN - P('i . ��LJ I am exempt under�Sec of ihe L A Co � iicENs� o �-� C[ss � � �"�-�� - Q � :. ;� �' '�%� �� 44 �' `.- �. �� ��" .� _ _ � ' c "'. Plumbing�oc�eand/or5ec o�fhe '`�� - DESCRIPTIONbFWORK" fEE�� , :, Fi�� � - U. , J '- �- r;ouses�weRcbN�vecnH�ro �aie " � VALIDATION � ,, � p�4 . ` �.., Q &P Cod ¢r rh followmg-reason ' - J eus ic Sewea,_ I! �. ��, .. . .. . ,,r� ��'x— �'—'—"^_�. .•- $EPTIC TAp k SPEPAGE PIT Q7E,... - � _- �- '. '�PIT5 qNDYOR DRAINFfELD � - , : . . FINAL � � . - ' � � HOU5F'5El*7Ek�o�UN cnwlGYd� ., . ev . . ._ . . '- . � � ` 'PRIVRTE�1SPOSAY SYSTE �. � ' -. �i9nmure .. � . _ cANNE<7ntr� r6N�`i�L6G 07+ .� . ._._ ... ..-.., .- .... .._ .. _.. �� CFC!J�IERBUICDRD�CLARATI�N .. . WO�TOHo�S�sEWe� ` � � `� � OVERfL�"N SEEp.4GE PIT 6RAMFlEtD ' � " , � � ' . ,. .,. . ._ _ : ,._x .., ' I hereby affirm thaL�`am exempt from ihe Contrpctor s License exiM";`ESsaOoi,.bkvwFtL h�.�hFolF - � . �.I,aw 4or t�e follQwing'ireaion'(Secton 703'i'.5,��8uisned's dni!Pro- �.! � �nt'ea,kFaata�oa ehtvooN nalSe � "' '` - � - � � - � p fess�o'ns,Gode) s�a oa oispas��svsre�n ,. .-_ , �`-1 fi G;5 A �-7 y._ .>. .� u..... , �,.�. �, _�. � �'.�,�LJ I,as dwne,r of fhe property,or.my employees�vith wages as �� � �� . � � . �r�.e..�• m�� � �. .. . their'Sole compensation,will�8o the wo[k and the strucNre � � � � � • r is not�intended�o-,offered fo..sale{Secri4n 70dd,Business . � . �, � �. e a 2.'�.���_ license�esstons�"ode� OW1yFER S Perm�t 8 ,�'G� and P �I as owner of the property am exdus vely coni acung w th AUTHE,)$fZATIOfd TOTAI.F�E, _ �� .� e � e 2 7,rj Q'� `� d controctors to fonst�uct rf,,e projecr(Sect�dn"7"ba4,` ` '- i HA,�e AT TNis oaTe a coNTRncr wirN KH�HekeiN Karvreo coNrRA oR ro $u"snessandProtessionsCodeJ � � :aNNst-rHeAaoveoEScaiBE�ExiSriuG�weuiNG,roT,�,Evye�45ewfa«,_,.,,. � ,,,�:L(�-���.7� �.„ �:: �4'bNSTf�GC`T(ON'LEN�DTt�I�AGEIVCY' ' ,.� ' '�� ��_....'�+ / .► . .. . � . . ��I hereby 6ffirm 1ha1 16e e is�a c',onsfr�cfion�lending bgency" � SIGNE6�THIS DAYOF 1 � - , 4or th� performance.of fhe work fpr wh ch thrs perm t �s ~ �N6RbR�� � `- �- - � %i� ss�ed(Sec. 3Q97 C'v��C.). ' .. - �own��s.aGeNT .� �,�t': . . e y , ,aooqess '�Tender s Npme �, . �. . ..,,, , _ � �,�, ,._; , . ._.. ..,`^ .. .^E .: �. �s =..`�s'. r a' .. .� z ..., - " _. , ,-.le�der � ess � -� ,. �_, ., .. ., �,:� . . ,� _ �.�:_ .. . : . . � �- , .__.�. ' _.�_e.,- ..__.__� .. ._._ _..... _�._ . , . ...... .. . .. . . - ` i c ify that I have.read ihiS�.�application qnd state tFi6t the , .. :�. , , . , , �. � , . "'�:-a ove�infor 1'on is Corresf.I agreB io c6mpiy w,'Ih aIl�ounty � � � � '�� -� �� ' � ��� � � ; rdnances nd State:Iqws reg�ulating Plumbing and Se�wers, �- -� . `. � - � - ra and hereby author¢e�,represent�' es of ih�s'Couniy to"enfer -': ' '""��` , � ' �" " „' `.'._ . , ,. _�: .. ... _,- . -„ . ...� ..., . , : . _ ,.,_ . ,, .���:` upan tlie ove-men:' ed. 'pert forinspect�on .7po;e .`. . . . '�` . '..; �~ ;�. . ' ' �.� . . :.:� ' ._ �.. � `L` 2:.., .. . � . . . " � . . . � . . . . -�- , Slgnafu�e of Permittee Date� SEE,REVEH5E FOR�XpLANATC}RY�ANGS]Ay�.,; �_ � � � � �� .�: _ _ _ _ ;� :�� � .�,. ,��.'3���,� _m�����o�sr�ot� o�srr��-��n�.��c�.�°�zo� _.___ _._ , ,_ .. � �,��u _ .. .�e���R�F/�LS . �on� � �naaveNai•'s�sicw.�uae,. ,. � . . . . . . I herebq a4firm ahec�.em zaemptfRom tH�e Cicmtract�r's� . - �'-`.�•�'.. .: ,:, .,, -���License I:sw for the$o�faea�n te�soa(Sectiosa 7031.5,�..��..� < , g NEWHOUSESEVJEk. fI� � � . � , Wv.�t�'"� . . .. _,..:. . ,:.. . . �:$suama¢ss.gavd Professemas Cod¢):Asy c3ty or soatssty�. cOtiNtcrnoois�ot+u . _ �: .�, ..:., �. . , . .. , .. �whs^Fi requi�es @.Pe»iii&do cqa�shuct ad8ev-;`.sroc$roue,.:; . . BUttDING OR VJORK ' . .` - "� ' . ' � BfSb .. . . '.-• . .. SEPTIC TANK.SEEP,%TI57 �-.. _. ._._... . ... . ... , . ..�:. ,_.._.""'_..:'S-,� ¢mn oT T sf9 T�. SP SfS aSSk6fSO¢. . . �� o r8�45ma,[any ucta� ,f�reoT u w, _�, � ....; aN�ioa oran��iFto.� � :,_ -.. . .�� .> : - �. . "...atso'reqa�ires i��,pF?�'icRRa�os Such:perar.+a8�Po fede�.a C�.sscobt� oavx�u[]. - `�'�::� .. , . signe�staaemene SbaQ.`br wv ddeer.seeg pursu,assa &o tXre -. . , ..._.. . .., ,_... ,.�.,. . ... _ . .. ;. . ... �. #..� ".,. �"`procri.c7�a.€pf 8ba 4.onYiv�iYoy�s Lace��I,szad'(G'i�aAter�9� - ALTER,�REPAIR,SEWEROR ..�.�.. . ....,. . ..� ', ..:. �l . .�. " _ .�OOri91EE92C643g LUfEAS.FBCt36ff 700��O,f DN/f88091 3 0�3EC.� . � SEWAGEDISPOSAlSVSiFM , � . . , � .. ,_,.,, ��.. ,...».:. v.�. ...+_,-.. _. . �, ..w......,..:. .,.... . .. .-�. . •' .� . , un�ess a�d�ro"�`esssoru Cqde��o,r"t�""a't$o�ss ex t� � `U�SCONNECT.PIUG"AND • ��. • .. ..� . ... . ..... �. �. . . . ....� ......_ . .- :�, , ..,"` . ` , ..`_vsob'at6ora'o��ir"o»703�5� donTl � �P,PT S)PQ icessa�ts D _:. ,.:,. rt, ,,. 1.:.,: ..._ y��a ,.`G_:, �.��,,.�...f �.:.;fwe�sai3red�Thrs(�5001:�z�n�ed exeenj>tsmra A4,y,..�..�. , k'BbNDOU HCUSE SP,WER BI'�'D�_ � � ,�,�> . . . 00 � R�&y U�H80$9PdOP�J968f8 � ,-•.__. ... ..... .. ,.. - , . .: . ' • ' . , f .. ;: �m�C � �-'., a h _�.�. w= : :. . �- ��.:�[1 I,as'ehc mwnxr a�tflee op �wifY�da tfie'a�orle,and�r .. t . ,w _,._.. „w ., ..,-,_,�. .�„o �,•.r,,.�,r'. ,�"'�"�'_ ` . Px EtYp' ; � . .`'�-�--. _.._. . ...:... ..�.. .. . . ���the strueture is'ana.iutiended..or uffered fossale: .. ,.. ;, . . . . �-�.. �.... , ��.:_. ..� . � . .. :,,. .,,.�. � . "� ,.'�.�� . ._ :::�7Ser 7044;.-Bmsisa�ess and Pvofasslvris•Code:��The�`ore-.' �, � m...__ . . �_..:.. . . �........ ::...:.._. __. .:..� . . � ., . .. .�.:,...,, � .. . .._ . � .. ...,, . r ..' . ,.,: � ar"actar's"L;izetase`Eo¢v�3oes�ao��`a}i�8y�Ea�sa��owaaai'of'. 3 __._ _:_._ . _..� _:._F.,'. p - . � � � . .�� � .�- .+,�+'operay wbo 8ui&fis or,mnproves 8bereoss.and�wfie r8oes' . � �_ . .�. :..... .�....._ . .. ,.. -, 4,r;-_�.. ' ;; .�, ' � "sucb xtios�k���b'�icie7J"�£Pvidril t&at sucTi aoeaprovevieemats � . �, .:: �:_:_ � � : � ..: .�. ,_ �..�, .- ,�-- ' �""&uelds��or�¢roaier eRtg:sfs'alid".utbsci�e�ysai��of`- . :. , _ .. . .._. . :. .. . .,._ :�. ._ : --_ . . _ . �� '=� � ,;.;. .- , .:,'.' . :., .� . _�� . .'. � �.�soria�letiaas,-Efie oriisaer-b�si7d�'r.airilT have tbe buide�,��� �- � '�-�: — -� � ,-rr �5', - - .-of prove�ag'6haa be d'wt�oe„bt�l�.ar tbratisoti�jar ske'� � ,.. . .. . . �. _ . ,., � .,, a . � . . . .:,, , .:. . , , '. :.�.. _ .. , _ ; •r _ �urpase ojsale.3- , ., ,... :, � ., ., �. � � , - ,.� 't' �c I� � : .� ` 1��P e�pt�iiid�r��,ec.____.__W__��____P , , _, __ .. _� _ � . , :..:� , - _ __ . ' f ' .,�.for tizis reaseesT t. ' ' " " `i. _ . ' _ . � ,.,....:__. . ._ .„-;° .. ' :. _ ., � � . ... .. , .. . .. .� . ,... ;� .. . :.i_C .: . ,:�. .-. ,-, ..,. . ..,, � �... . . .. - .. .. . . . �-q ... . . _ . . . ..._._.._ _ . ...�_:_.. .._. :...�., . .,.._:�. ,,,-.,_.:.... ,..__...:�.. . . .:, .. .. .'. %I$$E°..,�: .'., .. 4 , - . .. . . ��-. .1 .� .. .:�_ . . . . .. '.�.:; . .- .�,., ._... �...: „���,- `-� o :v-�. .s . � - '.,.. . ..,�, . .'._ , .... . , ..., ,:�: �, . v ��. . .';, . :�:.;. , � . . .-�.,. � ;:. .� . ... - .. ':. '4NSPECTOR'S NOFFS . - � > ,. ;�: � _. �. . -. � �;..3 e a, -�,.m� ' . ... .... ,... ...�.. . ,...,:.. .�.:.�. .._:-..,.—,........� - .,. _ �...�, ..... .._� _...,,- �._, �� . :. . , �i: � , .._� . .� '. . .: . .�.:.._ . .. ... . :... . . . � .-. . , , .' s .. .. .. , - �. ,: . . . ' ' . . . � ?,r:� �. ���; �- ��>�»�..-,M,.:N r��-,-,: �- 4 a s. -�-�--"-�=- _ - � �a,�.r„,� i ,. ,y �� .,.,�,.. ._. _: n , i. . . .. , .._d,.;� . �-.._._ --�" . , ., . .. .. ' � -;s `" �",� .... . .� . . . � �, �S'��y : 3' �: +R" . . : �� ��� _ . . . „+t ,t ;:`, �"r �` ' �; s _T. _„ . . . � �---�-� �c .r.�.f . . - ., ,. :... ;. .. . : -- _ - .-: . . -- .,- .' - ' , _ , '.�,� .� , ,ti_ .-,_....:,_... ...,,.._ �...�•.:..—.-_..a.�_._...,,..F�...W-v a�..�. .t� �w TM�*r^+':F -�.-.�r�,�`+r _.. . . . . , ,,d........ . , . . ,�.. .,i .'ii �> . .�._.�i..., , ,,;• � � �" ,; . . . � :.. . '. '....,, _ , i.; .f,, :.�,if� .. �� - . ,, .,.. .. �...'_ . _ . " . . _ . ,. `��:�r^s; �c.`x4�Ni �mn ,a.r;w��+w„w,�- ..,�.�,w.w,*�:x+s'"' . .. . . . . . .. . . , . �:� . . .. . . .:. - ..� ....., ..: ., .. . , ��. , -. --.,'a..-^=�-^-'-"^..,. .,.',.,_ ,�,,. .,..... ...,�..-�..�:,.._w...� �.:,,�..�..�.,-..... ..M«,.�.,e.-�-,.v,Y.a: , . . , .; .. � �,� . - . . � . .;-»-„a. , - tr.<i*�,-+�r�«„«:..+�ww�"�iw�.�cs,uwr+^��'�„'.-,...,:.. . � :. - ,.. n: .u„-r -�.,.�«: ,.�,'< . .. � , , _ .. , __ .... _ .. � . . .. .,4 _ .