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\PPLIC\TION FSR U11-DERGROUND :':,NK RETROc ZT, OR PIPING REPAIR PEPMIT <br /> "3ZS 7ERHITEXPIRES 90 DAYS FRCM TF A?PROV:,= DA._- DO NOT JRITE IN .AA: SHADED AREAS- Iu37CvM PERMIT:�'pf 9-_LO1: <br /> ?AVK R_:cArIT PIPING REPAIR <br /> ZPA SIT= X ' PROJECT CONTACT t TELEPSCNZ I 73qon, OC 4(,�I 33 <br /> c f =aCILI:Y NA`L �1 �r \� i` ��`, PHONE / O!"w y ,v��.. Lr,�2 . <br /> a � ` R �-1 h3-r.� <br /> C` DRESS ybCA C . \�G�rw1e S'11vo mak. YN C-C I <br /> Z r � <br /> CROSS SZ7ZEE' I <br /> Z <br /> T I OWNER/OPERA. 1 PHONE i <br /> © LOCO �n , �� A 1'�b0 ?�b-�i 13 2 <br /> C ; colr—CroilvanE ' 1` '� `V `C7C1�f�C�Lt-�7�5 I �ICONE320 -1 -�t blJ i <br /> o � <br /> z` I CowrRACTOR ADDRES 5 ' �c,l r I CA LIC 2 6 L M 1 L I CLass� C <br /> T � W � 11V77 VV R7 . <br /> R I INSURER ` ` 1 WORX_COMP-2 D\,ACO <br /> - <br /> A - <br /> C I OTHER INFO"2.ATION I I <br /> T <br /> O I I PHONE 4 j <br /> R <br /> PHONE 2 I <br /> lt7 of lfllttftf l[[[Iffilltftaf if - <br /> �f[1[[[ltilll[7lll[►l tli[illlli <br /> TAvK ID S T:+`_; SIZE QifliICai.S STORED CURRFIIiLY/p_YEVIOUSLT DATE US' INSTALL ED <br /> { 39- 1 1 S <br /> T I 39- <br /> a l 39- 1 I I <br /> 1 39- I I I I <br /> 1 39- I I 1 <br /> �1111{IIIItIll11Ifill I1IlIIIIIIIIIlli!!!11111I111111111111[11111111111111 11�1111111111111111111Mn 111111111111111l!!!t{l11111 <br /> ? � lI <br /> :.. I <br /> APPROVED �APPROVED WI-SH CINDZ:'=0N(S) _ DISAPPROVED <br /> ATTAC41fYr W117CONDi IONS) <br /> .= 1 ?LAXREVI<-4ERS :rA[c£�.w�- /� DATE 1 <br /> —�11111[if fill 11111Ii1111111111ii1ltilllllllit{EliIltltitllittlllllllli!{tllllltltillllltlIiiilllliltllitIllllllllllilltll!!i!!I <br /> X?>LICANC MUS: 2ERFORM ALL WORX IN ACCCRDA_VCM :':H SAN JOAQUIN COWTT O?J)INANCES. STATE LAWS, AN'J .2DLi_S AND 2BQULATIONS OF 1 <br /> S",JOAQUZN C7UNrY ?UBLIC HEAV-1 SZRVIr'S. OR LICENSED AGII$'5 S7GNAT.TRE C_'raXF1ES THE FOLZOWING= 'I CERTIFY THAT IN j <br /> ',' PEFFORMANC- OF THE :CORK FOR :IIIICH THIS P_'IIT IS ISSUED, I SNAIL. NCT EMPLOY ANY P_-RSON IN SGCS A MANNER AS TO BECOME. I <br /> 573.T£CI' TO WORie•-2'S COf1PENSATION LAWS OF CAL.==O.ZNIa CONTRACTOR'S HIR-�1G OR SUBCONTRACTING SZGHI:VRE CERTIFIE; TdE FOLLOWING 1 <br /> -I C`_'RTIFY Tjiw. Iv THE PERFORM--vCE OF THE WGRZC FOR WHICH THIS PFRMr IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WORKER'S I <br /> �JltPENSATZON <br /> :_AWS OF ZFORNIA. <br /> :+?PLICANT'S SIGNATURE- TITLE <br /> BILLING INFORMATION= <br /> =Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> pe-mit payment coverage per tank- If the party designated below is different than the permit <br /> applicant, e-g- property owner, zae party must acknowledge this responsibility for the billing <br /> by signatLi e and date below_ " <br /> �aLme 1...11yC IV cp��res:J53`S WiqV)a(y'\ phone number ),0'- �4 6S3 <br /> S-gnature" IJV <br /> T�:H 23-0038 ( <br /> . +-010 <br /> {- alc ne+� 5rn1, ( v ►2 ��y Sao- <br />