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SOUTI#SAti JOAQWN COUNTY FiRE AUTHORITY c o mVItNTIT RISKit IXX`Ti(^-DIVISION
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<br /> PART I Inv;vz'titm Regwar Lim(2091131•673F
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<br /> PR[iIFV7 li)FN'TIFICATION LICE SEDCA,VTRAC7r1RDM.44RAFly"-
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<br /> ,APN:2[317461 C %vW T �t era I T-4111I Uax_ 2 A DESCRIPTION OF WORK- OWNEx.&C-AL YEAPACLSRA>rfnr'.
<br /> LUQ►F,S-DFMO 15,000 G A1.1[?1ti ABOVE k e:oc'r' I s Deme+>tnd Ru(a.rars C: je}ANY err .KE regaix,r sK*mr+�r.+p+^�er..e n,rmf ewe,acer�l th,>A
<br /> GROUND DIESEL S1ORAC E TANK «fah my"alarr Friar u its imuih.e,rho 1"ofc,the awiviiri for heti permo W rdr:s s yard=ull�rcrr far•c ar
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<br /> PRO)Pi ISMD USE OR OCCUPANCY. K1t1r3t of ih,r.iwi I ur,'w[lsmms aril Pmre.i.rI Cssekk of 16.t c ur ehe a nrmpe leer Am and the earn f a the
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<br /> RtXBV LAID COMPANY 1,al rn.nv ow rhr r+x'r'errS or Int rwiiiyw�with wyp:.r,llitif s.•k JLq 4 i u vt w
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<br /> PHONECoils:U&C'awtraalNl'.i.wea.r I.w aa.linl awly IN ra.rrn A pe.virrty who hewhls rr+ vt"'.1 rbw m.MI.MK,
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<br /> CO TRACTOR• .ill ha-t Ix hvdm aiproris ja O:x`-+t yr Are did nut bwild v gag.uae fx s!e VNPK ur salt I
<br /> APTINI FEDERAL SERWES LLC _I.um v—yr tar PI%vrt7.an:c.6wt th you uw.uor with Lraasll"wawfwa w sumtrwt rkw Ix*o(Skc 70"
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<br /> PHONE:2259326SQ4 FAX-- M Q rr ares 5farnx avd whn cmar'.a tor mch rd*KKl M-6 acutrlrarin"Ixcrnrd pR+nwwyl I"vw ovomr snrl
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<br /> STATE I.1C'F.NSk NUMHF•!t:99VAM I am a .*L.atrs Ser. llasioe..awd 1'n iewarrty G ufr i.draw wimm
<br /> C'IT'Y BUSTN"S LICENSE NUMBER: [>Mnw. •Dere
<br /> ENGINEER OR ARCHITPCT: ■Y::ra�s m+yrtass+rrorn�crur�rre
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<br /> APPLICANT: I cervi rt ttai is,ite yKrfw iraa.s.irde vrcsi fw vbi ih din P",ii w iswvd.L"I w:cunovy aey ptnka in my
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<br /> I CERTIFY THAT i RAVE RFAi)THIS WAXNIM'p kAll.uler:Sb strrRF vrokeKE>R5[gAdY�1�515T4gy crllreRAl�I�4�fI+1R731L,
<br /> APPLICATION AND STATE THAT THF.SII01C N AND MlAt1 slaf CT AN EMn OYER Tr)CluaelNAL PENALTIES nem CPAL Ferns L'r-ro0N1:,
<br /> INFORMATION'IS CORRECT.ANE]"I NAT I AM TIJE Ht-%iVit Lin 7,WX1SMFJ DOLLMLS(SIOMMO),IN AIN31tI?N IV 11M,CW Of C'OMPnv3AMN
<br /> UV4NCR"OR DULY.4[TTIIOR]�ED AGENT"OF FEES ASPROVOCE)POR IN NHINC04 17CM01,It1F L.AWIlt CODE.INTftI,• Av77AtfI1RDAMAGESLYS
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<br /> TIAEOV4NER-I AGREE.TO COMPLY IkITI{ALL
<br /> CITY AND STATE}.AWS RELATING TO BUILDING ��a�srxrK rrr�ti cE.snr�rt frf:Sr r-
<br /> LON51'RIICTK)N.I IIERFHY ALITRORIZE
<br /> REPRESENTATIVES VES OF TI M C1T1r OF TRACY TO ApPh mi of'mu ansa dw pmwJA}'v1 peTxr dwt Iiorrr e;w whxv kn$94g agrucy for%hw Pcxtormancr of
<br /> the WOK fY whidi 00 Pa1vxl Witsvel3($0111 m 3W,Cn•,Ci Lrnires
<br /> hN'TF.R THE ALif2�Tr f�1kN'f Ic3NEU PROPERTY FOR yam -
<br /> RNSPECTION PURPOSES_•RLlquims wI Wille
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<br /> SIGNATURE 1 y hm
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<br /> PRINT>�fA1� 1} !X E Q
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<br /> I OWNER* VCONTRACTOP 'Any P1.o Rr k-Der=wrv.null...d.tea.p"ON-F.lrcrrorLrD EX:mv it w;mrs f.�dr eAd�ref de
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<br /> AGENT FOR C AGENT FOR
<br /> 0%WERr• CONTRACTOR OR wore_A VAUP Prk MIT KWUL13 WHIEN PART Ll"r,MMO it Tek[sotnll Stu+,pnA[)cir
<br /> I7IltIhrY tFIREAlf3HC►I1r1YCOM7liuI.TTY'RISK RIEMTN]N DIVISION,
<br /> RECETVED BY: DATE:
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