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Revue ertricex#w Ur d Sues.Safi • the Cal fomia Department of Benefit <br /> pay fsr:a�O Cal fornia Division of Industrial . 1 also understand I may contact the Califs a <br /> Contratoirst-i or .cslb.ca.gov for more i�ifo <br /> about : . ; <br /> t f am a%* at O*w4kdder bui ft perrnif appNed for in my name,and:wWii id <br /> s at l am ft @andTma-responsrUe for propowd cor iori a(AMy.- _ <br /> 1hj611. I agree that,as the party lolly and financially responsible for this proposed c onst� <br /> e <br /> malt al'rca `a:;r< gi„re�f; as los, , <br /> 2. t aOa to the i s` m xe t f a s, <br /> pubfic rcontM17, r�e vaaioAss`te a <br /> Y , <br /> un. <br /> nable to� � _�k a _ <br /> unficensed Contractors may be in cid f <br /> Contractor or employee of that indivW of or firm is insured whHe worldrrg on your property,ytw maybe held liable <br /> for damages. If youDbWn aow*i6 � yr `#o-hks7 + sy b s ie or <br /> verifying whether or not tlmse Contractors are prpperly- and the statusof workers'conipensation <br /> insurahE;e COvetage <br /> 37 <br /> Before a' bier, �� " <br /> mss barb - <br /> i4 r,-0.17111 <br /> AMM <br /> WIMM <br /> "" ;. •`-r ;:.0 C`_. .-.e' six ts.... :ra '? `,,r•'r''-,s,t ° ' z 2' ; SuS+a�r'3r _.... <br /> drhFwfs fog Or <br /> to be presented whm the perrrlit Is Esseped to Verw dw pmowlyawnees slg <br /> Property owners=e a �, 3` � Q 7 2 <br /> Na �Pri�ed} . � <br /> ply t :: : <br /> Authorization Form is requires(to be completed by the property owner only when desUnating anagent of the <br /> ro atmtr-'apply-for al p O err ;s <br /> P ABY' <br /> AUTHORIZATION OF AGENT TO ACT ON PROPERTY OR'S BEHALF <br /> I fterei yai rd ie `PonsolKs)' --act as,my-g (s)to** ,-doc�M#s <br /> necessary to obtain an Owner-Binder Permit for my project _. <br /> Scopeof-woric- P� o, <br /> tl <br /> i <br /> roiecf'b <br /> P -- - - �- <br /> 17LI <br /> Name t1f AcdE,or�ed Phacie C.r `J"/ k' <br /> Address of AWmrized - <br /> I declare under penalty of Bury thaf"i ath-die +e y=aMrAer tjpersona#Tfflftd <br /> out the move irdbrrnation and certify its accuracy. Note: A Dopy of e_ouvWs driver`s :Abim <br /> ProOwer's Signature: Date: �7 " ) <br /> ICY . <br /> F, Suldw v nTc&Wn Fomcloc 2 of 2 <br /> (Poiind 227-0 <br />