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APPLICATION FC2 UA-OERGROWD =;-VK R'TROc IT. OR PIP!NG 2EPAZR PERMIT <br />-3IS ?ERH:: =X?: -'ES 90 DAYS F;zCy TY_S A?PROV;! ,pa.__ DO vOT !(RM Z.i U,t SHAD,'D AREAS- ZYJ:GI:E PEAM.IT -:YPf 3.=)Af: <br />' ZPA S ZT`-- x <br />a <br />c I z3DRsss � <br />Z t— <br />Z, j diOSS SLZ[-EET <br />Z , <br />'T jF-R�OP_cTLA'IU.2 <br />�j <br />C i CONTRACTOR .4AME <br />O • <br />L` ! CONTRACTOR ;.DDRESS <br />T <br />R j ZYiSURkT2 <br />a <br />C OnMR Zwo:R. AT_ON <br />T <br />o <br />R L <br />_:AR$ R:_ OFIT PIPZvG REPAIR <br />;"Ra -ECT CONTAC' i TELEPSCoz a <br />CX LTC 2 <br />PHONE lci � - <br />t PHONE et <br />?HONE a <br />2 <br />j WOR7r-Ca+P_2 <br />I PHONE I <br />t PI(ONE 2 - I <br />[r[f Tf rrrrfre4r4l eif frit er Rfaa rr - <br />�I[1i1611a[TAXr `D[g/[ei 6t lElll( <br />! "f: -S' SIZE QIFnICALS STORED CURRENTLY/P-REVIOUSLT DATE US: IRSYALLED <br />T } 39- <br />A } 39 <br />! ! <br />i.. <br />PPROVED U-IT.(S)DZSAPFROVED <br />AITS C ArD: IOTLS?LAN REVr.-[ERS NAM£DATE <br />IIIJillIm I i I i i I IiII1iIIIfIIIIIIIBIIIIIItIillliiit}Iliilliilll3llltl I MU I Ml UM"", <br />.12 LICANC MUSS 2ERFORN ALL WORX '-X AC. CRDAVC-'S ::Z;TR SAN TOAXabr O2DLCATaCFS• STATE LAWS. l,O .TDZ S ,1ND .REM-KnOTLS OF <br />1 <br />S,I.Y JOAQ(ZIN COLDKZ-Y ?(ISLZC t1E.AL=3 SzLVI(_S. C:-?=?( OR LICENSED AG4T•5 S:G;iAT.JRE C`gTIFICFS THE FOj';_,W NG- 'Z SRT-F1C 'Z7yAT :v 1 <br />'-!,- PE-¢FOPr1ANC= OF TYE WORM FOa -3aCH TRIS ? 3ZSZT ZS ZSSZTEp, I S=L NCF ZyPLOY ANY P5RSOM rX SUM A .MANUM AS TO a£COnE- I <br />SI4SrCT TO uORX :R' S COMPES[SATI402� TAWS OF G1L_-.^RNIa,.' CONTRACTOR'S HY2= OR SUBCONTRACTING SZGIZaTRRE CFRTZFIFS: T3E FOLLOWIId -- j <br />rc dgy z5;. L-( TTIE PERFORM; -VCE OF :iiE uOZK F08 NIIZ(HTI(ZS PrRRII- IS ISSUED. I SHALL EMPLOY PERSONS SU?'.ZECZ -o uORxt R•S I <br />N.:t":>AT30M-1-US OF CAL -AL. - - <br />,.?PL7Ci�NF'S SIGVATTJRE:�U7 9 TITLE` <br />s3 TLLING INPORMA-TION- <br />indicate the responsible e party to be billed for additional PHS -EHE) staff time e:Tended beyond <br />ae=mit payment coverage per tan-Ic- If the party designated below is different than the pe -mit <br />a_bplicaut, e=3- property owner, t -he party must acknowledge this responsibility for the billing <br />�v si a, lI: e an ate below, <br />Name address <br />c <br />gnature <br />!E111 23-0038 <br />K64 <br />c <br />eA -+ 0jr d w j . <br />