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.�N/t�RICEkS Cl7MPENSA7'7p'N`tlECLA�2A71aN . - `�:T�:. m ��4 C .�Y*.
�I hereby aff rm` t'6at`�i. have a c'e,ri�itate'of cg,nsent�'1''a se 9E�e�oaW 3 e; "�.�� ,, fi � y �. .- _ . � , .. . .
«..�'�.�.t,.w �aaan2o . . .. . .
rn6ure or o certifmata of WorkeB�CompBnsat�on Insurance or ' �' ' - 'p�� ' ' �. ,...,�, ,� ,,, _,, _ ._,_, �„ _. ,..
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,-. 'acertfied,cpythereo (S�c,38�0,Ca C) �.� � . ` . . .�. ,�pP���p+����N���a� ,P����� �.u. �
:�Pol cy�`1 -Compqny_��.,fl-,'t_�..IC'�/�6.°� �is ' C �1 �[ y . . .
��Cert�fied copy�s hareby furnish,, . .�_., ��_: . . .��:' �cWER ':.S�W~G� ��S,�QSA'}.�� , ...
�� Genified copy is(71ed with e co ty b�{ildln '�napepion .� . . .;,-. -, � -- , .y.,� � TY �� . .
COUIVTY dP tt?3/[FfGELES BUI DING,AND A E
��dePart ent. �.� - � o . .� , .. -. . ,. � . - ,
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,�bare,,/���!R�.4pPl c� � �=f�!i�«�6�.���'� F�J�APRLI�ANT TO�I�.G IN � GOMNECT�CSW DATA �
": CE fIFICA'[E OF E�EMPTIO�IV�FROM WORKERS e�itoiraG�. I �� � sr.anoN � oevrr+
- �* GOk+IpEfySA�f6N�TFT�`,URA,�C�' . ' Aoorz�55 , {?, .. .,°",*` � �,.�.,
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,.�(This sectiqn ne�d�4l:be comple�ecf f the wrzrk tnvolv�c�C�y rha� . ia`A�in, - �� rowNHo�#neFeReNCE °�'�` ., �owER'-
x'p�rYn t s for one I7undred dollors{$100)or Iezs) hEARE51,�.. �� � � ' � � '�"'� tvpepFCkNNEcrla�7'""""'""" �. i�NGTH F 'M �
.�
-�e'rm�it�is issued,I�sha I nor em io��an ersok for h�p}�'+h�s „ cRoss sr, � � ��� v. .cuze e� �. M�To P u�.� f
� Q the wo �. �
- p � - P Y Y p n in any manner �,.�.:, . ,.,..,... .,..,.,x ...�.�»Mw�„�.mo„�.�; .
. a.c r�o ��C� ,, .'
��;so ag to become sub�ed to the Wnrkers Compensavor+laws _ owNea� � �� � co iMp No.�� �os rvo �
� "�. .sw'a"• �; �`FS' kt�.�s ••s K :;. �.. �'-.k ,;�-�d ;: � �.'�. Mnu-. ,.. .._ _.p��- . . _ _.,_ .._,�
. , �. ��J _ ,..q y,'�,;". .;� �, � ,/. . � �TRUNK PERMIT Np . ROA�PERMIT ND'. .�
. . . ... :`� AD�RE55'. .�. . . . , �. � .
�bate "�APPI cant . . .
x�xem +"on, ou "should iiecom'e sub'e9t to the Woi { � a � d��onvit' wa�vee �e.nse�seNT REcoRo iNsre No� oare�� '
..h N�OrICE'1'O APPLICANT If�after makin ths �er(ifrcate of pTy . set:uo �
. ,.... _ . ..
' p _.. Y p ...., I t?_. - . , �.�,�... . ..
� �.with s�ch Q i d ...,._ ��cAt. �_ �,. � .._., _...., _�.�..._,
, f hW)fh �ESCRIPTION ��Tryp �� N1VY ORST.WIDENING �
.,,b
p. ;..���plYnsation rovprdv'sfornshor.PForPer�mit sha I befde@�I?S. . .. .'.�. .. . ..
. � .. ._....
' CVOkG'C� . �� BLOIX TRACi" , . SiATC ENCRaACHMENT �,� ` �', Y ' � _� "
" . '- NO OP�LO,GS ' ' � PERMIT NQ
�:;TICENSED CONT�A�"T'OR�DECCAkATIQN � � size oF ior Now oN,c_i �- �� - � ` � '� �
F" ;I hereby df4irm thot'�I:qm liceasec��„u Y(er provisions of C�aptar ��oF'� ` """"""`"'"'""""'"""""' �"" ~"` ��� �
, , _ .
,i,9�commen<ing with 5edion 7p00)of Oroisi�n 3 of ihe4Bus . eu��oiNCS '' �- � � �. '' � � �� ainkGes' `
. effect. Profess�ons'Co�e,pnsi my I�cense is:in fytl forc�e and.,,, . �� --_.d�- - _�-� � - -� y � � ' �- ' --"'�-'
.,�ne�es a`nN . . �� .."`
, . . - . . . .. .�. CON':RACTOR' ,., H`�'R
CONNECr�ON;C GE FEE� . .
,x : ;, ' . . .�' . . .. . _ ._ .. ,.�,. _ ..,,w.»_.. Y
,��L censeNumbe. . lic.Class �� �� Apb�SS ' . . - ItEIMBURSEMENT FEE � � O
• �:.� . ° _ .r . <,�, - ,
', -�. , DISTR7CTN0. GROVP MAP �. �PRCCESSEDBY'�
� Contracl r Date � - CIrY ' � �rv0 ��
' `�' � . STATE' ' � ' � - CLY55 "- � �.., ��� �y r 'yy�7� �
U
BK, �'}vG � O
, ❑I am exempt under Sec � of the L A Co -, �.iCENSe�No'""' � . �� f,
,. , h fallowin�� � . ,„�. ._y •.' _-_., " -.` " � . V.
- B�&Pi�,Co odfoa t'i : � ' �` No � 6ESCRIP(0(J dF W01�K fEE" �
. ' !�/orS�c " ofthe . .-. � FlNAt
. " �r9 -. ' � HOUSESEN1ERCtiNNEC'i(3Gib'' " DAiE � � VACIDATION a'�
; 9 fEO50n ��PUBlC3EMlER .. � � �� �, �a�� � . -
� ..-. ..»} F:- ,�+ :,, 'SEPi�CTANK,SEEPAGEPIT4�R '.�.. ".' .
�
, '�� ��PIT$ANb/OR.'pRAih'fIFLp .: . . ... . FINAL. �'. Z
' �q� . . HOf7Sf SEWER-CONNECTING TO_' � B�
� y _._ _
" ;• � � � � �� �' .-':PItIVA7P➢I$P SALSYSI" " � """'� ��`
��I he�eb��a� .�u,u.. �,..�«.. . . ..
r C�ontraCtor'g��L'C, � WORkTdHOU5E5EWER � . . �....�.. .^.� _. ... .�.... _� .�...
g u - ���NF7NECTADUI710p L'�'6DG'O_ � .. - . -.
" y'_ OWNER BUILDE�DECLARATION � -:,. , �
�o„,+-_,.,. OVERFLOW SEEPAGE PIT.D2AM'IE0
y ifvm iha�i,J`am eze,mpt firom the � , .i�en,se �EkrN cE5sa6�t bkvwEti,nn.ewHoie �
._ �.
� Cow for tlie following`ieason(Sec(on 7031;S,-Bu sness pnd Pro` _ ��a�rers'aevA�K�"ottn9r+ia�oh�F+o ;!�"r'""""'" , _, � .
r'fess�o�s Code)� � � seweR oe oispo�nt sws�,u" ��9 �4;1�A�
.,.: , . _ _ ._
�� - ❑i,as owner of ihe�property,or�my employees with wages as , � . � . ��•m e c.� Q,..
' � '�'''�their sole compensafion,will-dn ihe work.and the sfructure - ' �,-����� ���.��.-.-w��,.�
is not-ntended or�,of(ered fo�sale(Section.7044„B�sinesg � pe�mlt . $ �y ,�',� .�:�°���rj� . .�
and Professions�pde) OWNER'S v
.._.�
[�I as owner of the property am exclusiv,ely cantract ng with AUYHOR�ZATiON TO'TAL FEE m , s e m 2'7,rj Q�
licensed confraclors fo co�,nx�sfyYuct the projecl(Seclion:7044;'" �'� �HAVE�AT THiS OA7E A CON7RACr'WirH iHE PEREIN NqMFO COfJY2ACTOR?0 , �� ..
�u51nE'S5 OnC�Prof255 Or15 I.OP�} CONNECT 1HE ABOV�pESCRfBE�EXISTIN6�yWE7L1YJG Tb TH�Pl1'Bl(C S;�IpJEi� r„ ;' , .t Q,'Z�..-���. . ,
�� CON5TI2C1C7101J'�ENpIN�A'U'��t�CV' � � - • � � � . .
.�� I f�ere�y a�firm�"��at�ihere'�is��a.�consiruc�#lor,v._kend�ng�agertcy � SIGN�D 7Hi$ �� DAY qF �� �� 19��.-
, ,;.fo1' ihe erformance:of the�wo(k for which th s� ermif is " Owr�Eq�ors 9� � .. ,
= �ssued�-(Sec.3b97,CiS�C�) ,�... .`.:""".` p..- . owNeaS nC,�vr ' . . .
', „ _ _ - �. � AOORE55
"` Lande s fJamz � � � � „ ,. , . „ . . .
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.,tBflf�Ef 6�.QC�(�IC83 � e .�. . . . � . , . . P.-.-,.. _. _,..
.. g P Y ...... .�, ._ , ,;. K_W ;
. rdinances and S,tate laws re olat VIum6 n and Se'the � � � � ��� �
I,ce y t t I hqve read lhis appl cafrorc and siote iha , , _ .,,
' and,here�r ation is'�c�r ec4.'16 ree`fo ro1� I wtth ali Caunry � � � -
ve Pnfo �
. . . 9 . 9 __ 9 wers � � .. . . .
'%- ❑ufhonze�.represe�ntqt�v�s nf"this Couniy fb�enler"' �"'"" "" ` � - "' �" "" "- �� ' "' " �� �" ` ' -" " �-- -
. .. ... . .__. ... . _
� upon th a6ove-menti d pr .etR/ or in5peciion p�rposes ' ' ` `�`f �'' �' � . - � � -
� �- } �
� ' Sig� Perm�tfee , _,,, 6tl�1�3�/' �<<�� �� . .' . SE6R�VENSEFORE�CPLANf(iORY.IANGUAGE�, � , .
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. ,., > za.�.»-�t,-r ...�:...,.�,,.r.� _ OWNFIZ�.LTIL.I7ET�33ECLi#��I(Jl� .
�_ _. .. , - , ,,.,.,._
�PPR��ALS onre orusrenoas si�Nnr'uxe _ _ , _
..�. .. ......,Y hereby afa:em rhar 3 am e.e2aispt ftomt6e Gonaiactor's-.
NEW FiOU�SEWEk � ..�, , � .. .•�. . .. : . � . � ..'�'�.8C0U9C'a:'aW gOY 4�It�01�8Wit9�zC850A��5¢CSiOPY�QS��,J�✓..�..
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_ . .. ... _ _�/�`- ' . , . � - _ �,.$aessn¢ss:r�asd Profe.rs�aoaa G'adeJ:.fsay olty:or.eoaenty -�
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'cnniNEcrnnoiiidrd`ai" .:�,. , �,� .. � ..� :-d�besFr re u9res a eems¢ta cos�mrasct, mF�Po s ,
' BUIIDINGORWORK � ' . � ' '.:.' '. Y � �.14�yYDSB>�
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�.aHQioaoaawFiFio �, ::,. '� � ..= i 's....: ' . ' .. � �-' '., slso reqissrea t�s a¢&(scceus�}'�r.;c�k7fTerm{t:.co f!!e a . .
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. . __ ...__ ._. ... �= -........;.. ...._. . .. . s4 ed st¢tememc 83rdt�be as"8eesiase� ursuxaat Eo�Ebe
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