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1643A (9)
�� I he eb affirm that I hav��e a erb cate o����������� '� � : ��' ��� � ���•: a� � � ����� �� ��.. � �.��>�... ' � W6RKERS COFl�P�NSATION DE AR7STION . :. . ,. .'''"��"'�'�� conse�'nr�'o''"se��` "-" va 000x ovw 3ie� . . . .. ,.. ...... ...-_ ... . ,., .. ..., ., , -.. . y ,. ..w .-.�;« w�.�w+. ,n.,....:: �vensa2o . . : nsure or a cerhficore of Workers�ompensalion�ns�rance or, , . �E�8 .� /\pP�,���TIC��! FOR p�RMIT � � ;`a ceri f ed co y ther of(Sec 3600 Lab C) � ' �'Pol cy'Kl� ��Company '�*''r'-J �JotlJl_ � �s .. ���. ��* _ . � �, > � .�_ __� ..�� .r., �.��..�:�.� w_. _ ,. � :°� x,.. = �cour��voF,cosAHCE� ; . �P�SAL _. , L7 ce�+f ea�oPv 5 he��bY fu�n;sh S�WER SEVId'AGE DI5 � pv. IES BUILDiNG A AF�TY �.��Cerhf ed co s filed with e c unty 6�i1 g in �� ron .: . _ ��^��'''• �^��' %��°""��^ '^��-^��.'��'.' deparlmant �.' .� . �..� -_ _ . - _. ., ... oare�����y�Applica + FORA�PLICAN7TQ,�FILtl_I�������`��� d f"g CONNECTIONDATA � ,_._ � w.. - CER IFICATE OF�XE PTI N�r,�F-�RdM WORKERS��� -�� aui4owc " � sinnoN '",ay. �'j . �TH - •. :i� t�1s..E�,S��O�IVJUR�� : .. ADDRE55. - . . "' �. �,� _ a�:�x, r w.. s ,W..�..; : . PP ..; M. � � ....�....�-q �_.,.�(Th s section n,�ed r�d,1'�e,co,mplet��i�f r.qe.w�myo���„(iy t�e - � ., .- vaNHoiE.R�fEREry[� /�- �' ' peth5it is for ong hund,red dollars�.,($100)or less) ��uTY ,- . , : . , ,- IOWER � NE¢RE�T.� ... - . . TYPE 4JF CCIKINECTI. . ,��.� 'iEN�`,7fI'FR�`"��. ._, .. . _.. __ .»,-.,r._...«-,..�..r ' 1 rert fy ihar in ?�ie`peiformqnce,of the woik fo�which ihis cROsSSf -.�:+'��=+ v ���. cues � v� � rd i io P`C; � ., .., �� ' perm t s�ssued I shpU not employ anq persqn in pny manner �� �< � � � � " ` p: nio '`� " �:' so as to bepom�s bject to the Wg�Cers Cqmpensahon Lqws ,;:: oy,R„Eg' . - . � co.�mP No;.. �tie No � . 'fi . , . , ". � .,...,« �����,.J,,-•....� � �� ��� ��1��� k., r� _n � h�, � � • TRUNK PERMIi NO , . ROAD P RMIT NO.._ , .� ._ .. .+� v . � r,a .� ADDRE55 � v ._ _. . , �� DPte � A�IPIiCant . „��„tA, „",,.,, ,. . . .. •. ......^ - ' . AfFIDAVIT� WAIVER EA$EMENi RECORb.iN5TQN0., .� OATE�� �' : .�' ".. ��,. .. ' . N07iC� TO APf�IICANT If after me�C�g tFi s Cert f cat� of �iT ," ., _,- -et.N � . .:- mM`ply wifh soch provsionscor th�sspe md.shplrlhbe_derkers , t�GAi �. - ` ' ... .-- - "" Ex�ampt on; you sho. ..qrf.l.g i , � - . p - . �,�.».. Cbm'pensahon provisions of the Lpbor 4ode.you must for�,hw�h , oesceianoN lotNo � �y Hwv oesr wioENiNG _ .., ; - emed . . ... , / rnr N . `. ,.: ,:� reVokCC�H,, . . , , BIOCK : TRACT � + �.. . ��y RO(?CHM .. , . S E E C ENT NO CUG$� P�MIT NO , _ .� . ... -, .«..,v�.a..�_ .'� �°CiC�'NSED�OI�TIi'A�T��.D�C�'TI� � ,�r y, srzeoF�oT - Now o�t c�r .. � - `� " 6 �_ '� � � I he eby,of#irm that'(`am I cens��under prbv�siores o�C�apter �y�Op- ,��. �� �<=;'-TM'^�^w^ff .;�"'� -�"�'�"' . . �� . ' ��.�9(commen£i,ng wUh$e<f on,7A00)of D�visipn 3 of ihe'.Busi„ „�.�., :gul[DftacS � - � . � � ��� " �� n�ss aRd P�of'ess ons tode,and my I cense,is in full f,g,rce'ar�d,_ _ -�� '�� ""�'��^` -'"' "� ' '�- y � - � eYfe t ���, .,� .-�. _ .. � '� cw�.rrzpzroa � � _ ..a,,....,,�,m„�., > . HAFGES- . G ONNECTION CHARGE F�E �.. �m �����. ,;, : .. „ . . .., -..-..- .,�...�. . . ".�"" a :� LicensgNumpe Lic Class���,� � ;;,�,; nooaEss� � ., -.. -,. ReiMeuRsen�NrFee _, .,A m , -__,. :.. „ p. /�j� �ISTRICT NO. GROVP 7xAP 'PROCESSEl7"�V"""" U. . , �� COn�IQCio�� � Dpte � :. � ' CITY 'iE4 NO $Yf7 ' ^ � PG . O � lame� . 5'n7E��, . q /� u � xampf under Sec � of tha L A Co � _ u�tySF No �. V q„/ c PSS � ""-� � . 3 ��-- ��' - � . �^,.;�: '�'� : No. O�SCRIPT�ONO"'rWORK GeE N .. ..e-. ....,. !>. ., ,..� � . .. ;. ; � Plum6ing�odeandlor5ec �ofthe � .. „�� a � , , : _.� .. ,y �.NOIJSE SEWER C(SNNECTING TC3� bATE ���ttt���'�_ VALIDATION, � B &P�C�od ort e f,ollowirrg reasonT_�_:=_. Pu9LtCsew@R'. . `., �7 Q� ���' .`t�l . . �. . . SEPTIC TANK SEEPAGE PI OR � ,,: ""..'� , .. , � � � . .... ._d , _.r:�:e'rv^- . FINAL . .......-..-e Z S. .' �� .� .r' . PIFS"A1JD/6k�DRA(RFIE�� "� . ;� .'' <. .... ,,..,. ,.. . HOU5E 5�R'CONFJ�'CI"NGTS�'" _. .w...n. . . eY .ig . � � . .. , .:....-. .PRN TE'JIS �N$1$'fE�! � _...,.. ���_�a,,,,,/ . .�ICfflqlUf �t. . ,nv. �. . . .CUNNE<T M�IfIp IfAlPLOG�OR :'.=�. ...m•»•,'�:.'^•,-•, �••_,.:._. ..... ........,. ..,�...:..._..._...._._ .: OWIV�IF B��D�E�DEC}.yRfS�FIO ..WORK ib HDUSE 5EN}ER� �: . � . .. �m,., ,��(S<,,,c.,.nv�, OVER LOW SEEPAGE FIT,DRAINFIECD . ;�� I hereby affvm thof I.am exempt�rom the Contrac'for's'Ci<ertse exrN,cessvoOt okvweu n�.4Nr+ote , .,. ,..�,�.:„ .. .�„ . , ,; Law for.tlie following reason(Sedon 7031:5;Buis�ess and Fro _ � _ � - A�TER aePA�R 6R q6aNnOK.Fit�5E „ ,.�_ ,_,,, r�(>�Q,�,�j A� � . �. fesslortSCoc�e) ��� � � ' -� SEWEii-URDISPOSA15V5T�M'. . , .., . .. «_..,...... � ❑I,as owne{'ot the pwperiy,o�my employees wit,hmw6ges qs ': � ' '� ' . ��� --��.���.o e e..�.� G . � � , :� -.Y.,�..�.., -.. ��- 'their sole 4ompensahon wJl do the work and the stru<ture ,,,�„ . -. � �- �. '�- - � �� . �� � . - ' - ,,,is noi intended qr offered for sqle(�Sect�ion 7044 Busmess .� ����OWNER�S.� PQ�mrf ' �� TM g ��„ �F} (���o i�^G'],5(} . ._ . a� � and�Pofessions�Coc�e) : �"� `"``�" .:—,�,— .. . . . . . ❑ I as owner of the property am exclus vely cont ac�ng with AUTHOI�IZATIC�N YpTAL F�EY.. m e �G��'�5�a . '` �- -licensed 4ontractors tn�cons,eh�ct ihe project($ect op,7044, i HqvE nr rHls oaiE n CpNrqn�r w[rrt rH {T�aEiN NqMEtl C NTRnCroR 70�� , � �.2���g•7 � au5 n255 al]d P�o'�BSSIDIyreS COfjE} � CONN�C1{jiF�A8Q(E 0�..��„��.EX�SYINCo DWECIiFG'Y�TNF�,Pl7dLIC�SEW�Rw ' : �- � COt�"5�f�YUCTtQKI LEt�YD1NG C,EfJCV , � �'"'"'j°` -' ` SIGNED THIS � � DAY O� ��� �- � i he eby-aff rm ih6i.ihere is a���cpnstrvcP�n lend�ng agericy�� owNexok - ,,, for the performance, of t�ia work,for„whic�i h �s pecm t Is . .� oyvNERs n�eUr- � � . � � -_v,. iss�ued�(Sec 3D97,CiJ.C.). - � - � - - } `�;: ,' , : �. -: nooRess ; Lender'sName . . ,gm°+��*x.^„"a�,� ,. , ..,. . �,. ...., ... . ,_ ..,. . ,. Lender,s Addregs N� ��� ':� z � r � Y � � � a���B'nf mat on�s.� _..�,.., .,K.,.� � r��.. x..u.. � � �. . . ..._ ..w. ,.� �, w ..� '` '�read iFis'npplication an�c sipte iF�ar the_,_,, w,w„� � _ _ � , , . � , . , . .. >.v. _. . .... . �..-F.. .e ., .. .�.,t ... . � i '-carrecf.i agree fo comply wiih al7�ounfy ' '��. � . �_ ..� � ,.� � � - � . ;:.;.".' dmqnce and.5(a[e laws regula,tfng Plumbmg and Sewers�. .. . � . .:.. . '.'- • -.... .'" ..'.; . .. . .. .. . � . . � , "'�� �and her y authorizG repreSenYati es,of�[F,is County fo enfer `... ' , . .. . .�, ` :.'. . '... . ..'. -" . �` .... �: . ..".. ... .. . . �"� upon th_above m twne pre}�erty for nspection purpbse,s `, , ' . .. :. .. . , . �- �� � �S � � � , _ � _ _ .. " �SEE-ftEYERSE FOR E P A,AYORW iANGUAGE� r Signat�r� errs';Rtee : .. � p� - .M..I.N, �:,.,.,.�...�,.-,,:.�.. .. . .<:..�.w. .,.�. ...�,,,„�-�,ra,.,,u.,�...t �»,-..����-,....-«:,a.w�.. . .. , . . . � . . , ``a..a�.-�;,.�:�_,�- - ,-4`�� _ . . �� � � „ , �. . . _._ n�� ,. '�� : , .. , °::� .°° I�asP���oe s n�o'�s ��:.,.��. �U�L��AZ 1�EC�A�`d'�(7i�7 . _...�,� _ „,-. _�..�..�.�.� � .�AP�ROYALS on� ' �iNs�crou•ssww.ruae..: ...�` ..,,�„_�_�__,� .�._. . . ._,:...: i�hereby 3ffirms€hae fl ace ezempt�fro�x3�e�;avcracmr-'c�._ . � ratw HousF sewea � j - . �%�, "�. , ._ . .: , � � _�usescsess�`ased�Psofessaoics�"�od 1@asoa�lS%ty�or,a�t�ty� - GONNECTA➢DIilONA6 ..,'=�,���Y�. �'� ",.': �. ? s; . . ..'fUFJPd'�i i�8iKC5.!p¢MSit t6 C6RSWlECt 61.C¢9'.Z�d�POLCd� �. SUIL6ING OR WORK. .. .- . . ....: . ..., . . . ` .. . . . . � 3EHIC iAN%,SEEP,!qT(5) . ' � ' , . " "' �, tX9iNOIfSIl C9'�T 6PJ SSMLCLYtYB. m $6 8d'�su�tc� '. . ANuiorz oan�r��in .. ... . _:. . � �; _: .: ,'d . :.. , v��atso raqusres ab� ..licanz por sscb g5er�rais��io,/6Te s- � ,.....- -.-.. . . -... . ,_ `.�'z i " r a. ' � ` ....�,- .�' :..,�ss"gne�l s&eCe»ac�rt t�.be zs 8seew.ted jrursaan8 ta the � cEsssoox C7 oRvw��p � , , . ,', �"�..'� ' _�� . . :. __....... . �..-.. . .:.�. ..=:�,-:....... :.. ..:. . r ,pravassosat'of S&e''Co�4&sactos�'s Licr»se Lath(Cf.e¢paer�... . . nt�tt:ttepnrR,senntre oR , �_ . �.,. . . .. ,f„_.. ' � ., �,..(co�norzessc%1ig wix�fi�,Seeedo�x 71t00j�oj�D vi.cio'a.3 0}E.Sv, � SEWAGE D75705AL 51'5TEM ' . ' ' .:• "'— .� d,. R ' � a. . C6iL�¢)�� 6r]�31 p^¢Y'S Ndfi . UISCONhIEC1'6WGAPID . . �.....:�'^- �." . ..-,�.. . .; :-:.. �.:�:.. . •,.4, -: .m �'IDffsi9aes&��Y'6�e,caYo4f.c o9. . , .e.'�� k.. . ... ...,- ,a A alloo�r+ous�sewea ,� ., � � � . , .:. b�fro. �� abe basis far dbe�ddege�,rs�zmp83on.�Iny: nr and - ea�ac s�ttic TANKs p .: . ....._ . -.. :.. 1 . ;: .e r... �vio tiori of Seesdon 703f.5 by�aaaY cpP.iscanc faa�Q perm5a � ss�7,��i s ❑ cessPoots[3. � . ... - ' � �.,, ' ��.sacbjeces tlae�ppJicama to a cYvid,�+rea�Jay of saas enn�e8san_�. ... .� ..... . ,.. � ;, ,_ � . :.. .. .. �., .�; -;, �,��. � - fsv�e bmn�red daYBa:+s�5'SOOJ,i . . f� P,es vhe owuer o�the prop�rtq iwi3T do tfie'is�isrk snd' . ;. � , !: . . , ., . .. A . . ..__. .. „ .'.. . � ...,. .... ...:. . ` .: � i....... �'. � . . . .�.; ;, �- s,`;.tha sczuc:uee is not in4zuded'or o�ced Eox�scle�.' . .,..:. . .�._ .,...__. . ..___. . . : � � - . . , .,.,.„PSes. 7044,.���Fixasai�ess��m,�ad e"�rofecseosss�£."'ade:�'�2,7ie Covs-:�. - . ;.:..... _. ._:..... .. :. _�,._. . . :"� ,� .: � . . . 3ractor's$ste»se'Law�iYoes�soF-�vp¢ty�40'ax�t�?un¢r oj:. . ; . � .. . . , .� _. _ .7 .:.s,. �.-. .. .. � . � . . . :: �_ - . .. . ,...� �.. .„properey wba Pnsllds ar svn,¢s^aa�es s8erema,mnd au$o.dosc�. . � , T �- ,.�. . .. .. ... . ,;�. _. _. :„ -., : , .�. srscb work'�ismseY,p`ps•ue�r'ded tbat'srec$i�ra�eroveenerats �.. .. . ., . ..�_ _ . . .. � .. , s .� .. .. . .: , " '��. . „�^ �"""� 1 c� ,��,sa�pde a�2��id�buadd.•a1e fP;bcui¢,ver,ake; _ �� ` _ � � � rurtfi a'mn�'ymm'af� _ _,_ _._ .. .�. . � � � �,_ .._ u .._. � a, ��a.r k t ti ... ' : , .. .. . . . 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