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WORKERS'COMPENSATION DECLARATION ' � �
I hereby offirm that I have a certifimte of mnsent to self j �
. insure,or a certifimte of Workets'Compenwlian Insvrance,or 7ena1� . �
a certified copy tbereof(Sec 360D,Lob C.) + ceeoe�a[v.eiei) APPUCATION F'OR PERMIT � - �
PoliSry No. - Company - _ . 4 .�s . . �
�Certified copy is hereby fumished. i SEWER = SEWAGE DISPOSAL � �
�Certified copy is filed with the cooMy building inspection J ! � U F OS A EL BUILDING AND SAFETY :
, .deporlmenl. . ,
Da�e� Applicant FOR APPLIC NT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' 'i �itpnic � . �
COMGENSATION INSURANCE - I aoorsEss O� � suiion oevTH
(Thiz section need not be completed if ihe work invo�ved by the i�i�n, � � M4NHIXE REfERENCE L�o�wc�R
permit is f«one hundred dollors(S10D)or leas.) I
NEIIREST TYPE Of CONNECTION �[IJ�7H FROM '
I certify that in the performance of Ihe work for which this ccpss st. � Y. CVRB P.L. M.�.t�P.L ' '
pe�mit is issued,I:hall not employ any peraon In any manner P�NO 0 i_
so as fo become eubject to the Workers'Compensation Laws. . . owHCR (1 �O.�MP.NO• JOB NO.
��� TRUNK PERMR NO. ROAO iERMR NO.
Date Applicant � � � A�REu . �
� NOTICE TO AP%.ICANT: If, ofter making this Certificote of �, �i Q?' ���.� /Op �FFionvir warvere ensevsr�r 2ecoao.irura.r+o. wrc .
Exemptio�, yau should become subjeU to the Wakeri � ��
Compensolion plovisions of�he la6or coda;you must forthwilh oExaicnp.r �otrio. j � Hwy.pt sr.wio[wNc �
� comply with wch provisions or th�s permit shall be deemed �- '
rovoked. . � � �ocu TRAR STAiE ENCROApiASENT .
� ' UCENSED CONTRACTORS DECLARATION - - rio.or xp�s. a��+ir r�w. ,
I heroby affirm tha�I am liceesed onder provisions of Chap�er 5��toT raowora ior i �
: 9(commencing with Setlion 7000)of Division 3 of the Busi- euqwnws aax,�s '
� neu and Professions Code,and my license is in full force and '
BIfBCt. . Cp.npq�7pR ^ � CONNECTION CHARGE FEE
license Nomber � Lia Glass� App�� � REIMBIIRSEMENT FEE � p'•
� CoMrodorc��DO19 D�STRICT NO. GROUV MAV sxo er tQ7 �
'7 ^2�'�' ��n ��.�v��- 33-3bn� � ,, ,� _
❑I am exempt under Sec. of the LA.Co. � i���,q. �n��,a,55 f �� � � ��
Plombi�g Code and/or Sec. ' ' of the "1O� oESCRiPtiON OF WORK r�e i G
MOUSF Sf WER CONNERtNG TO DnTE /% �+ .
B.8 P.Code for the folbwing reason _ i �u&ic s�`"'tR _ ..f� VALIDATION y :
. � SERIC iMM(.SfEPAGE Fl7 OR FINAI � Z �,
' I PITSAND/ORDQAINfIELD
�. �l . �- HOVY$EWER COfWJECTING TO BY�� �� ' �
,, /'� � MtIVATE�ISPOSAI 5�5 M '
SignO�Uf! H.fY e0.��- ic ' CONNECI ADDITIONAL&�f,.OR
� OWNER-BUIIDER DECL4RATION i �+'o�TO�aus[s[weR
av[xr�ow y[o.,c.�r�t,dtairvf��o
I hereby oHiim Ihal I om exempl from the Comractors Licanse � � E%TN.,[E$$O�OI,DRYWELL,MANhKKp ► `���c3 n�„ !
'� low fw the following reason(Setlon 7031.5,B�isness ond Pro• � ui[u.rt[r�ia at nen�r�mori�ause , ��r a � e � � .
n�
fBSS10n5 COt�C�: I SFWFR OR DISPOSAl5Y5TEM . -
- ❑I,os owner of the proparty,or my employex with wages as �I [(- i� ' °i.�•.�7�
their sole compa�wtion,will do�he work and the structore � � ,e � ' ' '
is nof iNended or offered for wle(Section 7044,Businass- ;� � ° '.�,���!�,� ,
and Professions Code). OWNER'S Per if S �
AUTHORIZATION � ��•��'—5�
❑I,os owner of the properry,am exclusively contratNng wi�h l TOTAL FEE , $'� �
licensed comrodors b conslruct the project(Section 7041, � 1 HAVE A7 THIS DAT[A CONiRACT WI1H 1l1E HFREIN NAMED CO� RACiOR TO �
Business and Wofessiona Code). ; CONNECT TME ABOVE DFSCRIBED E%ISTING DWELLING TO TME PUBLIC SEwER. � �
CONSTRUCTION LENDING AGENCY , �
I hereby affirm thot there is a conslruttion lending agency SIGNEDTHIS DAYOF 19_
for the parformance of the work for which this parmil is ' G^'�R� - .
OWNERS AGENT I
iESUBd($e[.3097,CiV.C.). " App�u �
lender's Name � I �
Lender's Address � I
- 1 certify ihat I have read thiz applimtion and state ihat the I - I
obove information is correct.I agree to comply wi�h all County ! • �
ordinances and Stote laws regulating Plumbing and Sewers, � -
and here6y authorize rapres ntolives of fhis County to enter '
upo he above-mentioned �r p�r y�inspection purposes. � - . �
t� .J�, r�'� �—Z�'� I
SignotureofPermidee Date � SEEREVERSEFORFX►LANATORYIANGUAGE
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