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HomeMy WebLinkAbout0894A (4) i . 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 labor coda;you must forthwilh o�scoicripr.r iotr+o. 1 � Hwr.pR sr.wioewNc � � 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/ORDFAINfIELD �. �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�wiion,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 , $'� � licensed comrodors b conslruct the project(Section 7041, � 1 HAVE A7 THIS DAT[A CONiRACT WI1H 1l1E HFREIN NAMED CO� RACiOR TO � Business and Wofessiona Code). ; CONNECT TME ABOVE DFSCRIBED E%ISTING DWELLING TO TME PUBLIC SEwER. � � CONSTRUCTION LENDING AGENCY , � I hereby affirm thot there is a conslruttion lending agency SIGNEDTHIS DAYOF 19_ for the parformance of the work for which this parmil is ' W`'�R� - . OWNERS AGENT I iESUBd($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 . j i ri� \� � � � Z �f_ ; . � zb m�� z c '' ' a�>Q�� �, o�zc�' ° Z' � A $ ' � � � �QO �<y��;,� � p� �� � �, � . . . � , ��V_2, O p O 9�, �c� 4. O ��T ' � ' �` �_� yY Tq �pQ p G J'. V L �n O i �G� '�4 �q• � � , V"��' , . Y N �ie P.r ir {/� \ ./� ' � . , �"Yc 5�j �O 'z -� \ �o A 3p r . -� . . �h�d • �tc�h��' ,� ° p'�'r L�S/7 � � :/ ` � ..�t,�:� . `�� � �� •�r �1 P � �`�, l' �.� � � o � � ���? � N � � ��`. 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