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... � - ,�. . � �� �.�..�. � �� � � � -� �.�� �•� �..�..� ��� �.,�. x,.�.������,:� _�.���.,�.,�,�;� � =���r��w-W�eas�C�nn`v�3nr"��i d��t�+a'nr�d�r � �� , � �ss aoea o�w'�rsr � � �„. , ,_ I here6y��affirm t6at_I hQve a cerlificate��o� consent to self �- . - �'%� ./- . � � n5ure ar o certifimte of Workers'Compensaf on Msuran'ce,or" ' �aAa2n � �_ ,� ` �� ," o ccrtified.cop tl�ereof($ec 58'Y`b'Ia6 C. � :�. ceaoe ,/'1�P���r���l�/IY��V_��:_����1 1. ...r ...__ . . _.,_.,, .. ._ _ 1 �P'olicy No��.�or�tpany � � �s �_ � ,, �. >,. . . � . ' � ❑Cernfied copy�s hereby furnished ' ' , SEw�� `y��..,S�E�AG ��3�Q��� . �� � ... � sd coPY�s f"led with t couni bv td m ms���ctior .. ���I�T�Y,O��$���ii�Ltl��������� �. . � y ��� ��� ��'�.�_ �`i p ,� a n� �y g� p�� � E'� �` �fi�'°��1i�`�a'�`� Certf ,� _ �� � de artmept ��p � " � .� " .- .. t7are�Applicant�g�/��+�/ FQR APPLICAh1T TO FILL lIV ' CONNECTION bATA ```" ' . g "C�RYIFfCA'�E��E3��fvlVT�l`���fKn"�1Y��� B�IGDtNG ^ .��._ . - , ; � ..t CONiPEf.i'�'aTIL�7v"1N�l�RAt�T"��� .�" . ` . noeREss . , srn�ioN .�.f.'S�'a .� � �oevnr�'a .,.; ,_. ,:, a_< „ . , � ,- (Th s seS�ion need�ai���e cqmp'1e(e�a�Ihe work in.vorved,�iy the �� ��� � � - . � '� - .. urvea� u� LOCAIITy .. lE REFERENCE �+, � ' permit is fo one hundred dplCqr9;(�1b0)or less) .� � � . �� wE nv,�Ho . ,: ,� .• •. .e., , ,,,,,.o: . .��..�. ..,..-. .� ..�, NEARESI"_ '^ � ,.., iYhE'OFCQMJ ION� N T PRL'V.l " _ � � IE G H -. ,:.�� _. . , I certify that in the performance of t�ie work foC wh�ich t6 s . caoss sr � � v. '- '°tupe "� ��a.. „ M�io P,�: :�'� permd s issuetl I shall not employ atty person in an�manner � � ,. :- sd as to becqme sub�ect to ihe Workers Compensal on�aw$. , . � . �. � �P c No . �+'�7 "' t ��, :,,. 4._„ x;: ,,'.. oWNER �e � Co�MP NO.�.. .i06 t�0 � .: , �; ,„ . ... . p�sq _" ,. e.rn� � . `�� ,-.a:`. a � .eT �DRESS'�1 V: . .. .9 . . . . . � - : ..� .� . ... .+'+ � � -� �� � TRUNK�RMRNO ' R9AOPERM�TI4Q.�� '� �.. . �. D�ate � Applrconi� � � �� -�� .• '+� ,»x-^ �� . '.' :" ,'... AFF@AVIT" WAIVER�"EASETAENT ���REC01itl:"iI�YSTk�'1;TCJ': �bATE.'. «... Crnn I wbh�����v sionsao er makin '"� �If�TIC�'1` � g t�is'�'ei�ificaie of ci � � TE�'.N � � � +"- p �� yau�"should become�rtsu6�ed �..to rhe Wqrker; ,�. � � - ' � � .� LEGnC . - C3 " �. . �, p tion Provi`sions of ihe Lpbor tode,�+�ou must forrhwith �65CRIPitON iorNo fJ�- � � Hwv oa ST.wioeNiNc � -� � � ��- � '.�` P Y. P this parmit ahall be deemed ... � . ... . " :` � .. .,..... , -..._. ...__.....:_:. �Y@VaItOCI . .. � . BIOCK. JRACT � - � STATE ENCROP.CHt3�EM �' ..�I hereb aff rm that�.�ONI�RAC7'dl2S D�C'4Ak'J�TPO`t� ` ""'- - �. aEarVriT No . � ... . ..- . . r,yy-Lf�EIJSED� no OF BcoGS ` �� .. . S�ZEOFiOT NOW ON CbT " `" ' `-' . 'e". �..' _ .� . ,.. r. ,e. .-. _ „ y . am i censec�under p o'v s ons oi C�i'�pter use oF" �� ', c t� �.� �� � ., ��.9`(commencmg wiih Section 7000)of Drvis�Bn 3 of the?,6os- eunoiru�s . � ' � � crina�es � � '- � n'es5and Profess orrs;�ode,aHd my license is n full foree and � � . �, effect +� � CDNiRAC7UR � �' p CONNECTtON:CHARGE FEE" - � �- �� �L�censaNumber�,..I.���,Uc Class .�� .J �,� ��� ,_� � - - � r �. - , f �] .:._ ADDRE55, -� ��- REIMBURSEM NT E -: O _'� ConffOCiOf� @ !a"'�y�'"��7� .. .. • , '.` +- ff DISTRICT Np.� GRdUP � MAP... . �PROCESSEb 8%`..." (j .. �..., ... CITY . -TEL NO 7 t BK PG F. Z � � ❑lomexemptunder$ec oftheLA Co `: ceNSENo �CCtf� �q C�a.�� ,cca.55 � �:� Z-•" / "J �i � - , . F...h. l .„. .�-. 2 �.�..,._,.., � � C/� �..�. M. �..u. -, � ' NO � DESCRIPTIONOF'WORIC' °'k�€"'"�"" "" 't. P�umbing ea /orSec. - ofihe . � _ � FiNA� � - -tt ". ': ' .HOV5f'$EWER�CONNECTINGY6`. �' ..„ " r.y� DAtE � �� � VALIDATION ..W ' B 8p�- odefort� followmg�reoson � �: ��. � �Vue11c5eWFa .. . ' ... ��.� �°'?��� .: . .:.�,.��. ' �� ..� '-�..: *-•..� -, `�- + :SEPifC TANK.SEEPAGE PIT(1R �� - PINA. ' ..� �i .. . - :v,R`AND/OR D'R�CINFIEI"[5' . -,�... .. - HOOSE SEWER CCNNECTfIVG,i0. . 8V ;� ' � . � . ' � �CRIVATEDIP A�SYSTFhI "'� �- �igna� . .. � CONNFCfk�dIT�CJh7aE8t�G�OR ".."".�"•. . . .. � . . ... . . .. . ' OWNEti BUICDER D�CLARATION �wonaro"p`oT�E s�wEa . � .t , •- '" � DVER lOW SEEP�E PIT DRAINPJEIb . . . ... r - .,.-al.'a-..�� �.�. ,«. _ . .. _ .. . .. . . Lawrfor;he rm tha�'1�''�am axC'mpf�rorr7 the C�ntractor s l cense E� N,CESSe00f oevwELY;MaIYHO[� ' � v, Y , fQI�OWInC]'1'@tl50T�S9Ci0l1 7OST.S,BU Sf125§df1ll Pf0- ' '-:A4TER,REPAIR OR ABdN6p'J-NOUSg "�`�' ��"' � . � �� � - 'SEWER OR DISPFSSAI,5�'$TEM��'""` ��' �� � ;�fessions Cqd'e) �� '� , � . � �� � . . . . 0 I as o., _ ,.�. . . �. _. a ..,,- ., ._ . . .. . . wner of tbe property,or my employees wrth wa�es as . � . .� �� �' fheir sole compensot�on,wil)do�he work�and the siructuie � ��-� � � � � ' � � . . � is nat�'inteoded or:offered for_sal'e ZSection`7'0'4Y;8usmess ""' � - � � � -�� � � � � �:���cJ� ond P�ofess ons tode}" " OWIVER'S Permit g �f�, � '� ❑I ag owner of fhe.property,am exdus vely contrqchng w th AUTHZ�R�ZATCON 70'IA�Ff,� � � � � - ��-� a��� ��Q. . � licensed COIt�fO(t0�6 10 CO�SifUCf 1hE PT0�6CY�50CfIOI1,Y04�, � �HA'J�E�AT THfS�ATE'A CONTR,.qGT`UJI}�{'YHE�NERE�N NAMF6'C N�iqACTQRTp` BUSi r1ES5 df1CI f�roTE55 OfLS COCI,��. � ' . � CANNECT THE ABOVE�ESCR79ED EX�ISTING DINELLIfSf�TO THE PUBL'L SEWER. '. '� s 0`'L�-���Q -. ... _> GOF(�TRUC7(0�7 CEN1�1T7G"7SGE'fi9CS"'""' "` ���I hereby d(Pirm t�ia1 iherE is a cansirutf�on fendmg agency SIC,NED THIS DAY b �� � 79� :� . . � e�����.2�;�Q� ^.for_th,e perFormance"o� the wqik for Fi"c17�t{i�is�perm�t is °ti"�NEROR - � �. ���+.�•- :-- -�. OWNERS AGEN7 ' � ssued"(Sec.3b47,Civ`C) ". .` �� .. �� - . �. � � � � � � I Q��b-�v�.`� ' AooaEss . . - . , . �. .�., ;,.a.. � .. -s .., . ,_ :_ ,..., :.� _ �.,,. . .: :;,Lender s Name � ��� � r, .. .. �: ,. q . .. , � - � >. ..� , , . .e r �� „"°Lende�s Address _.. v, . ' ,_ :;. ... w �: .,� �t..i . -- _ . . ., _ _ . ..,,,- .� . �,.�,_.- .... �'w .. . .(._, . �:.�., _ :.r.... , _,�-�........ _', � , c fify that I hove read ihis dppl cation��and stote thai the .. . . � -� � � a; abov informafion is correct.I;agree to coinply wrth all Coanry� . . . � � � � � � � ordi� nces and Siate-laws regufating PCumbi�g and Sewers,'� � � �� �� �� - � � � �- - � - � � ..�and ereby oothorize representahves of ihis�Counry to enler . �" � . - � - - � up the�obov 'eni' roperry for inspedion purposes �' � : ' . �. �: , : ... , .. :- - . �-:... . .... � .. +� p 4 ,/�'''+� l�.�y..o� ,.Y'� F�^�ir�.`CT /'. . . . �. , . . . . �- � Signature of Permittee � Date. , � , , � SEE REVERSE F4R EXPLANATdRY LI[NGUACE�� �, ' � �� . � � . . '�..w . ..,��..—�;�'�.�..v - . _ r' :' - .�...;_..�'�t� c�°��ov�s < , '' � ta � .� : �t � �'" -„�a ..�:._.43�N�32 HUL�Y31�Et I�ECE!'R.A't`I�?�d �.� ... � fi. . �,. , W,.,-. ,.,��., .�APP�O�/AdS ��..... oar� iNsr�c�0es s��uri7ud�,.,: � . - �T . ._,... .. . . ... ... . .,� y� i lenceby aHi:mn zlnat�Y am exe�pe.�fi°ocn�e5ae Cqnaractcr's ��. , � --N�wNous�sewea � "'��-�- - .`. .. .. . ... �.�... ' . . ...:... :..I:icense�Law£os t7ae�#oIlowin�reasov PSecSaon?031.�'.�.� . .::_.. _ ..-. . .,... . .:. . .�,:..., .__ ��nssraesr:�nrd Psofesseaias CodeJ:tiny rldy �r cassxty.. � CbNNECTADDITHJNAL - _...., _ . . '�Wrii�'JsYmQ'.'6.'�YiBS a�6fYl8i�,S0 COi3Br7`AtC� 3£IY�Pn.?tJi]5f`098r; . � BVIWMG OR VlORK .,�,� � � ' � ��' ��p �y s� $ � y.s�q�y Cy ' SEPfIC TANK SEEP PIYIS) � �^ �. y . d8f1i0P OT � °0'82 d �.. � .. ,'.. .... C5i69 fl4'f P 9 qfdD/OR ORAMFIEfD_ ".• _ , t. .J .. � � �` } � .St��9t8(�SlaC6�B13t �kld�dl¢��o�AC2fdS�p19fY�8ff�Sq pY7¢cG� . . . ...�.. . -^�-. . :. ' .. @� PG L 6 $IJC � . crtssaia C7 oevwe«C7 � , % .�", "s-. ,., "'�"�,�m tAe Co�s�ras o .�,sc rr�se Laui f�kea�3er 9 � . � :�.�a.-e�`ania sew�RbR ..;. ., —_ .,'�� ., .� . ... . � ,{rnrosncevatsai�g untb Settxon TUOD1 ug.L)aozeyoss�.3 of e&e��. e sewnc�oisn85n�sv5� ' � �t •'°-Y��'-�"` . """°"'�uaase.ss"aa'i�k�rofas.�oaas Codes o'r tbat E+e e':ti 3��`anp8 �. . , ���.; ..... .�..,.M.... � �iscorvnctt Pwc-ann .� ..... _. . 'sberefr'om tiiaa abe bases;dcr ihe m%Irg�d e�empa4osa.:9ny�� . - aeneaoav Hous�se�a. .... � ._ . � !os' $ 6r ' pT <,. , _� . , . ,_... � ,aAcicFi�isErrieYaNrcS❑ � � . . . . .rrao .son.rif'ec'ois'703f.5,5g�aeeyd¢ frar�tfosape`rmik�.�. . - sEfa;vir�s ❑ cEssaoots Ll . � :. -'. �.. . . ~ � bjec¢s a e cay,pTss ��- , .l�enatsy v/aso . . ;' „� �'-.s=�.� ....�.�� � ,.¢:,,��. - — e g u s��owaer o£t��e��er� �r3ii da eEs�mose&br�na -- - ,,. , , � ...�.� �..«�»,�. ..��❑ � - � a PTmp tg: w�k,�snd. -. � i rT � 'F 3 rie . 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