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For Inspection Call: StoteotCalNf nIo
<br /> Susirom lor ork ori+bushTg Agency
<br /> Steve Downer .De>)atlmeTTtatdamTTI►y �ve+oprnsnt
<br /> OMelon of Codes and Stcndords
<br /> (209) 769.6$73 mo1ltgri6h�1ome oW Specht
<br /> }��:r1:r1111 Occupancy Pos Pagrat s
<br /> NTO 9Y1TT0C0NMUCW-.
<br /> CEStDEOfFOAMFORINSTpt1G�F1i4fi1�!'Aff11)�1IdNAl1NL> h��lt0
<br /> -Cusr«ti+r:�..o v:i.4.. ••� r' dilON T ?OWN AOpL INFORMATION+ b� ^' 3V">'x ) E ;D PARTMINT ONLY`
<br /> Nbtm2irilre�r.roa,ccvhrrP,ririnfirxwiYumnstsrU7�ieafbYiiir.l�' refer SE EW NCANT_ #�;-� =T ..t; .�1tL' - � rUSE'
<br /> I,UaNSEO CONTRACTOAS DECLARATION 114 Es ".:ob Pt. LAN"10"6":`
<br /> I hereby otMrn under penalty or peau y mat I am Rcenwd Park Nomef. IO.No. JM
<br /> u(,der,pravislarnaf. - ar 4,oammend with tg,N 7 7000'1.x:, ...,,i.
<br /> i. ( ne ,,.sr. f� ::
<br /> a al,4�an 3Ybf ilia t and Professtoris'CoCa,'orid my Pptk Addr6ss 7 1'Y5^4 E� 1�x N(�r^7 Q W-0—t �F
<br /> Rcense Is In tLA force and effect- '.I - -
<br /> ,LlCensB GQSSLC.M1?O. Exp.QO,tB CItY W -- �-Y 6- .n�5 a�
<br /> �i4/Y✓1... COU
<br /> (y� Divi �JL1/°►QU1l�
<br /> G Clasad By
<br /> contracrar Dore zip I`a(n I Unincorporated ind6Tp6ratecl •- '" fie Closer
<br /> 2.OWNER-SM)ER DECLARATIONt�EE k I�111� n y J vvUX0TION 1NFORMATIQN
<br /> t eRfUrn+r+det ry pf. that,l oral exempt, Ptfrlc"owner!5 �ri"lir : Na :"t
<br /> 'ftoiri'tNe dnYtdiSfdisYl��ron3 Pott aftillcrivinp ri7ri(Sac,r W 1.r/ L oA8CtI0n ti s ^
<br /> 1031.6),BtAtness and Professtory Code: MY dty or county
<br /> wrurlt rertukea a permit to c«tatruct,diet,llnTNWa.dernow, APPUCAINT±9W I O L-1�IjPf NCi -�-
<br /> or repdrany atrttctur®.pr4or to Its(s5uanCe,oW rogL*es the,_
<br /> app ant far such permit to the a cloned statement that.tie ar 13d6W6ACTOR ❑OWNER ®rJther�y
<br /> she Is Ikwnsed pvrsuont"to the providom of the Contractors' l{
<br /> Ucense Law(Chapter 0(vpwnencino with Section 7009)af,,. . 1 r Fee ReVo
<br /> DMmorn 3 of the 9rx tr M aro Professions Coda)or that he I Aclelr6ss'-"�j^!5 W. \AIA L.N 1� A� OV 6 �OW, .
<br /> ow Is exempt therefrom and the bares for the 011000d ., ,I' '
<br /> exemption. Any vtorotlon at Seeuon 7031.6 by arty o cant 14LR ICA �`r�l No.�-�7 '��7
<br /> w tor,a perr�it,aubfaats me,dppACant fa a.avtN penottr of alar._ . .,- ..-
<br /> more than Iwo hundred donarKSM-); t ! CoAficttoh Odt�"
<br /> p4 - v' eA , wee ArchitgCt/Elagfrleer � �• Lfc.No �
<br /> 09 e�ir'vn8ro1X"7rty,
<br /> IXm s'wlth' 669
<br /> 'they 3de,Canippn6ailan.'tw,Nf7D't6ftwgdC,Orta ftle.itYUC1lX8.1E < - `• �!
<br /> not Intended 4f offered Tvr, e,0gq,7044 9,w#,"*r cnd t Add(e i�, t':� Tel.No. t�
<br /> Profeulohs Cd2ler The Obn?rrdorSi9 ic?eirse Law Clines not opOV Routed S1''
<br /> tdanowner of jrotSer 'ti+MRbulfdsorth.weon,ond:, I., •.. ,r -. `'. '_,:' c ?L�� .';...7. .,..,
<br /> who does aurn waslt.twrlsQltar"hefor or{(7<ioupn hIs or her.awn „tlpoft Depattment app 1 0 .
<br /> emDtoyeet'pfoivlded tt16T subh'iritpr0vertian%ore not Intended ' SECTION 2-DESCRIPTION OF WORK AND VALUATION
<br /> or offered for ante. 0.however,the Walnp or Improvement 19 releo9e..and pcTyrTlBnt of fees this
<br /> sold wlsh)n one year vt carrrpletbn the owner-builder WIN have p _ - ----. J permit is kited only for Mems
<br /> �n off praNnp�t�ot t,a or she tAd not b ud-or Improvii rl� :"50Fi�_ T�� N.' +L•C�[]i� 41/!T 1`/� wits
<br /> L7 4 as owner off me am exclusively aontr4 e6WQ`wim y� i © 1, (' r p�1, �D/� � � /Iy I PEFiHEIT�f`' ` '
<br /> RcenW contractors to coratnx:t the pro�act(Sac.70", AN i F' LIKE E J k; -_-- f
<br /> ,&4n-*rKf;Professlons Code;.j",Controcfon License Law i't t i
<br /> /]n � H ACCIS
<br /> does no lapp vpinpw*of'prope�ly who builds or imPrcr. e r/-t/� !. J JdC �4�
<br /> tliarenn;d'"i Cdiitrtfcfs fat a'lat+prvvlacts with B `•- __f G -• .
<br /> 'convoctOf(3 oens"p-Mont Icr#*Cdntrocton Uoansa. SMP
<br /> ❑I�'r'i Exempt u�;u�r SSE' N,,, .,a!k P.C,for mts reo`sa+: / ,
<br /> A, nei 9:/14° ,z llle
<br /> 3 X125 COMPENSA't6bECI%1E;rATION
<br /> _64 ? • MSG
<br /> anmunder penalty atpequyaneofve-r
<br /> the
<br /> ,.pad Ilona;,t, ;.a.
<br /> 1 eandwtRrriaintalnacorttrlfccite`of"roraenT'toleM-lrisurs valUctffOn"3 -
<br /> for "en coriipensdik 1'05 provided fir by S4ctI6 37C�6T, ''
<br /> the Cade,far"itre perfgrmanae of the work;for Whlch'this-
<br /> It L�u9d"
<br /> i- 'tend wttlrna�ritaarr�'Ice"re�.c�inps�n9atlari'Inaurcmca'" -S�G1i(SINS`�ACG�ESS�RI�_SUILDtN�3'b�S�R.t�C'fUt'!ES ._ ..T. ., ,":",. �' .
<br /> gals ed+sySectton`3700,af theicrWCode:f&the' �]NEVIfi ,f 11VSfA�L s S�Cfl fatCt Pldri'ry�pr vGl NO.
<br /> Pod at the wprk for wri",thts per**Isftq..wd MY : , §, ,
<br /> work re
<br /> cCrYyi9nsatlon lrtsuraricb rimer and palrc q axtrrtber' 's
<br /> off?: Awn ng tp0'rts�ptc Q kbanG
<br /> h
<br /> Numuer f:1,4iher(specly) t ICS , Kl Tr n1C L
<br /> (IhNs tforttteephaf tae:Corrq�leted if the perrrHt is ar:cxN3 s: r T DIVISION PROCES$RECORD'L.Y'
<br /> lxsh etl dollars($,1Q0)OF lesa�: -' " P%v'
<br /> y} '1,:u,n - {, att�WkV2_ a� 1,;•. f.,_ - _
<br /> t ny tf,uf,ri'the per«rnan�e pf it�a wp,iCrpr f IGn this 1 Vyt? "L }V1iral
<br /> ' b Usued.I dVA not employ any pew in my manner sv
<br /> as becomeµbleat toworkere compensation laws of Address , 4k),611,110 96/
<br /> C omkcxorannpdaaproo that 1110VXkI t)eooma UA*ct to vr - e: r-.
<br /> C 1 tortlnvlth compN mn Dae fxrntel °f the labor . RkrSdE14T WA KJ U CC1 F6e1.No. /v
<br /> Local Flee
<br /> Q.. Lai'No. Aj 14:
<br /> LoEal HeaHh
<br /> WFALURE OSECURE:WQRKERSS.COINSATtQ
<br /> VPEN '4
<br /> ' . g, :+ ". 4
<br /> COVEARM R 4GE tStNlEtli:'AND 5FlISLL'SUBTECT AN'£MPLOVET2
<br /> TO CRMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED SECTION 4-MANUFA911URED ROMFJMIOBKE140ME INSTALLATION f obftc Worl a'<';
<br /> DOLT AM($1 !N Af>a1TK3N,TG�TNE;CLTST OF- ,. :, r:•s„ ,+,; r;
<br /> I
<br /> NSA
<br /> CYKMjj�ES' P3TWIbED FM NT r WSe T!O. 37iib" mgr ,Tet IVa ` ' e Ctmani'al
<br /> F 1PIE'LAHOR CINiERFSf'ANQ ATTORnlEVS FSS.
<br /> jr
<br /> 6,CON5fTtllCDON.LENDING.A6F.CY
<br /> 1 hwetny Gtfttr�i tp1[f!f?peh" W.*t�iot ther616'a Address.., , �r IVsgdtNe
<br /> cor4tok; ort' opci for4h*pertrsrnaance of the work" - Deofollflfvn
<br /> for which thlS� en
<br /> i5lS4l8�i
<br /> Lender s Name School Impact
<br /> Le
<br /> ,
<br /> A'dC9'0�U ?$, .-�,� ...+' ._ 7;o-,
<br /> ani7facturer'NOri rey
<br /> Dote of MFG. IA
<br /> N Model Name
<br /> a CMr4CA1tON Inst nlo/HUD
<br /> y,:-„t•.cerik{ytf�t•3,t ,h ��. i ettlOt:1FIB,�'.{.�'��L,Gt3f3IN0.4 '�TT."�,- _ r: w: ;k:; r-'".a ":'-�:�=��..:.,� ;.��re.. �L.
<br /> I � I��p f °Or1d a<GA 'r; ,,E a�?" : , ,i Sp .;� .L�rY' �k'sr;i:i�Ct .... �"T
<br /> 'otidv.n otrnQNprt #*aatr f• 10irX 'w11h 0q b”. B
<br /> aridlxautityesr s r1:y o SEC? $':`PARk p1HtJER,OFEQiiTbR OR'MANAf Eft SR�;F1AfIlItE,t
<br /> Can9tructlon and h9ret)y aAtrorl:e reprasenratives of than
<br /> jXatrertY fa
<br /> APPROVED
<br /> $Ip", rXp.ofltpGantarApent Doe (Signature Required) Date
<br /> HCD 60;We I(Rev,7104) CMSIR WTION; WHITE-DEPARTMENT. SLUE -APPLICANT, YELLOW-DISTRICT REPRESENTATW, MK-AMESSON
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