Laserfiche WebLink
S <br />z ! Oti1NER/OP-`RA OR <br />�I <br />APPLICATION '2 UA"DERC:ROUhZ) -;.-VK RZTROFIT. OR PIPING 2f PAIR PERMIT <br />Y:rIS ?E : =X?: QFS 90 DAYS F' :CM TFT a?PROV;` Da:T_ _ DO ZOT WREE Iv Ar- SHADED .1RZAS _ I'73IC;L E PERI:IT — 9_ lA2: <br />I zPA SIT= 3 <br />_:A?SX �:r_OiIT PIPI.CC REPAIR <br />2RROJECT CONTAC.- &TELEPSCNZ a <br />CSG r�_, i PHONE .ink -�hX- �I`t� <br />C i COKIRACTO.'i vN'7E . ; �. `Y/ c �.i �-C i� s . I PHONE 3 � V � - � b ► - � � � � ! <br />o r _ <br />1 I CONTRACTOR AMRESS \ 01 C C.L I G LIC 2 L b (b I CLASs� <br />T <br />R <br />I INSORER ` `�/' T' l..l 1'1 I +ORS Caine <br />A <br />C I OTHER INFO.;. ATION I ! <br />T <br />O I I PHONE 2 I <br />R _ <br />I - ! PHONE 2 - F <br />l 1 ilii{tli��li <br />i Ta.`ri: TLD S ' T: -ca SIZE QiF icm-S STORED CURRF_NILY/P_QEVIOUSLZ DAT£ UST INSTALLED � <br />1 19- <br />a I 39- <br />$ t I9- <br />X ! 19- I I ! <br />t s9- I 1 i <br />�l;IlllIli[illlllll[1I11ift11t1lii[tiifllltlllitij�itllltll[filtIil[til[filtll�itiftIl[filtili[ttl]Illttffllltliltllfilitl[Illtf� <br />? ' 1 <br />[ APP20ViD APPROVF� vZTIi CIIIDZ`=ONCS) ` DISAPPROVED <br />.1TTAC izx—C UrrI CONDI--rouS) RDATE <br />nA.Y EVIz.jE"LS ?LAKE yt�'�+\S L.P�P1Mi MY <br />--iiililiifiilififttfllitiliflllfiil[Iii[Iftlili[tiI lifflifiil[i11111111f1[liltiitfllitlftllffiiilli[t itl I11111[I111f311111i1 <br />MIS 7ERFORH ALL vORX IN ACCCRDAVCi:iC SAN 3 ' <br />.A??F.ICANr T OAQUIN �JaCCrI 02DL�ANC£S„ STATE LAYS. AND .2i7LES 1TID 2E�TLATZONS Or � <br />1 <br />>A.`Z SOAQUrW COW17Y ?UBLIC HEAL -4 SZZ vIC�-S _ C ---"ZR OR LICENSED AGM*S SIGNATURE C�:2TZFIFS THE FOL:OwING: 'I C`DiTIFY THAT -4 <br />1 <br />y= PEQFORMA[+C OF TY£ JOR1C FOa :4ZIC31 THIS 2= 1ZT IS ISST . I SQUL NCi ZMPIAY ANY PSR -SON T.V -'7,M A -ANNER AS TO aECOSE. I <br />S'S HI;IV- -Or2GvA-UIZE ERTZ� TaE FOLS1wxxx- <br />19ECT Tb 0OxPF2SATZON LAvS Of CONTRACTOR CKRCF <br />-. CnrrIFY TS;.. ZV THE PERFORM;' -NCE OF --FIE WGR=Z FOR vRICH THIS P53kMT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S � <br />CJHPFNSATiON :JAWS OF CAL--ORNIx_- {,� ,' 1 -\,''.. - I (� f <br />�-QS-- �J� \� �(�/�C DATES_ I <br />:�?PL)CANI'S SI�ATTFR£: TITLE <br />$ iLLING <br />T-ndicate the responsible party to be billed for additional PHS -EBD staff time expended beyond <br />De -Mi tpa�Inent coverage per talLlc_ If the party designated below is different than the permit <br />applicant, e_g_ property owner, the party must acknowledge this responsibility for the billing <br />by signature and date below_ <br />N. <br />S=gnatur; <br />Z�:H 23-0 <br />ud <br />r address2�S3.S�'%allx� m / (29phage number � - I-632) <br />i <br />