Laserfiche WebLink
\PPLIC�TION 'CZ UNDERGRO-Jt.D 7;wK RETROFIT. Ot PIPING 3EPAIR PERMIT <br /> -3IS ?ERMZ-Z =X?IFES 90 DAYS FRC-1 TF_. A?PROV1 Da-!-_ DO NOT !W-r IN Ar~ SHA LD AREAS_ Iv,-Ca-,t PERr.IT„PE 1=fAl: <br /> __,-A•SY .Z:,.Or IT PIPZNG REPAIR <br /> ' <br /> EPA S T"I'E 3 ' PROTECT CONTACT t TIZ.E?S-C1Tc C <br /> c -aCILZ:Y t+OVL <br /> PHONE C r7A <br /> aDa j <br /> I I <br /> I axoss s-IRSE:- <br /> T � <br /> "2 I �R/OP_�RA"ab2 1 P2iON"_ i ' <br /> C cONTRACTO.2 :AH - •q� <br /> O ' ! PHONE/ - - r> I <br /> r ( CON'TRACT'OR :.DDRIs _=1 �-- r f <br /> T ,�..J I C1 LIC S ON <br /> I QASS A f1 /� <br /> R I INS / ('� r'( <br /> WORX_COKP_2 1 <br /> a <br /> C j OTHER XIJFOR-ATION I <br /> T I <br /> O I <br /> 'R I PHONE I <br /> 1 I PRONE 2 t <br /> rrnv•rrf rrrirtrrtrrrv•rr•r•:• <br /> �lllit/1[iiT�vX <br /> IDt ga tll/ll!■ii� - <br /> T:�\_ SZZ£ CHEkIGlLS STORED CURRENTLY/PQEVZOUSLZ DATE US: 111STAT*E+ <br /> 1 19-^ IIt I I _1 <br /> �1;I1;1lIt1ifI1I 1111111I11111111IilIIIIIIIIiIiIIllitttitl11ll1lIIIIIIt1flllifltlttt1i11;1111;lMillilil[[1111I11I111Illttltlll� <br /> a <br /> Z. <br /> 1 APPROVED APPROVED WZTx IWDI=-ONtSIx T.7=.APPROVED I <br /> I_ - :SEE ?TIAC`n-rr ;amcovD:zoNs1 1 <br /> SI I ?IAN REVIEWERS VAKE_ - - DATE <br /> -i1i11I111I1IIIlfIIt11i1tIllllltllillilflliiillltl1i11ft[111;111111111111ItIi1111111I11iil1111[1111[1[Ii11tI111Silll1111111�iIii . <br /> a??LICANY ri215= PERFORH ALL vORX IN ACCCRDAVL<T .y;y SAN 30AQUIH CAOtIZ OZDL\ANCESt STATE I.AvS. 1WD.2iILES ;U ,ZE4y1,A-noNS OF t <br /> saN JOAQ(IIN C7IpNIY ?USLZC HEAL_3 S�tVICLS_ C-1 OR LICENSED A6IYT S SZGVATJRE Cr IZFIFS THE FOSS OvZNG: 'Z CntI--FY IRAX <br /> T4= P1=QFORH&mC= OF TI£ WORK FO? :4aQS T$IS2T 1S ZSSZ1Ep- I SpgL HCF E"PIAY ANY PSL IX Sri A MANNER AS TO aECOKE- 1 <br /> S:ISIFCT TO vORi�2'S COKPEICSATZO� LAWS OF Cal.==.^..ZNSa.' COHTRACTOP'1 HZ2_vG OR SIISCUNY3ACTZNG SZ�-Va:T7[2E CEZTI FIFS TaE FOLLOWIIZC <br /> C<RTIFT T5;.: IV THE PERFORM:',vrE OF HE VGR: FOR WHZ CH THIS PERICI IS ISSUED, I Slip-LL EMPLOY PERSONS SIId.IEcr_O vORICM,S <br /> �JHP�CSATZON ::-k" OFT- -1 <br /> ORNIl;' V-.7PLICAIjI'S SiG.VATURE ------ _TFTLE //'f I•������ �!/W' �J �.J <br /> B 1TUING INFORI'%TZON_ <br /> 2. Cep►i�Ki1 S• S V. A. P. �:. �- F+.- M� vpt rtmf G- Pt-M / p. <br /> •l, 5c�•4'ta., &M jr, j, AftL- p`,r- <br /> 3 p� &^6 — tit g �r <br /> Mndicate the responsib?e party to be billed for additional PHS-EBD staff time expended beyond <br /> Re=mit payTnent coverage per tamlc_ If the party designated below is different than the permit <br /> -xnplicant, e_g- property owner, zhe party must acknowledge this responsibility for the billing <br /> lz�v si}gnat:=e and date below. <br /> pfoawm'lzt� be <br /> llr <br /> S--5nature. <br /> H 23-0038 <br /> 1 - <br />