10 LATHROP - BUILDING INSPECTION fLOWN11WISE f Lf$4ND APPROVED BY TW
JUSPJ:CIJa 1 PPJDR TD A.PEBWT AMG GRANTED
CITY OF A
SLEM
-�S - \ Df
�, watd
_ ZWft Diablo
Is
Located In Locatim
U»Fselslfo Djdjw Yaa No ✓ lalldiaa of J
Is Pimaly Located in
ft C mswvaVm Ama4 YaM No
Permit to:
BUILDM PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remd, Install Siding, Cartstrtx:t Dock, Shed, Pool,
RepaidReplace. Other
PLEASE FILL Otrr LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSWq
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accord4-19,to the.following
ape13iftpftm.Owner's Name I 'm 1 i K& k b e L e A C R s e v
Address & Phone t o L 0a� 2.0n 5 f• 7Yty -r.- Yl
Amhitect's Name
Address 3 Phone II
Mechanics Name Q 1 k Co I n ry v &J A efc s
Address A Phone 13 Se wA 111 f f. i eoboAy I MA, (q W I ya I- (0/a 0
What Is t o Pupae it WNW R P_ S :l e N Le
mom a bu ov woo k Fiz An.e M a dwaanp,for how in"farces? /
wa buYatnD cmi"n to law? As6Nbs4
Eefrnatad coat 'l10,000 my e
�Ucw"
Lic. / 2 3 5 4 n of Applicant
SKtINED UNDER TILE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
LNsfpd Vc"uL
MAIL PERMIT TO: � '��`
No.
APPLICATION FOR
PTO
PER R RANTED
U� 19
APrD
INSPECTOR OF BUILDINGS
•1J.P..ln..l,��.4�i��o�.alt•
AWAS iCOMMON Badv% M.e.eLew& 021/1
Workers' Compensation lum amn Affidavfe
. . witi.s p+IndWl plaa ad bmkeag ac n
L3 Se�✓tall — sE � .c�U
do hereby•certlfy under t)n pains and peoikks of pafnp, dmis
0 a anemph* r providing workers' compeantka covetaie for my dnplerreea woektng on
• �Rr>ve�eQS � �tsrnN:� Co, �I�,ivoig � U1�J ���.?� 718�d'-Ua.
Insurance Company Peft Number
I am a sok proprietor and haw no one working fir me k any-opadq.
() 1 am a sok proprievor, general wmm=w or homeowner (drde one) sod how flied this
contactors listed below who•have the following workers' eomnpetnatiwt p*Ndm
Centreaw Inwranie Cempatry/Po Nxmbw
Comtaaer Insurance Compaq/Po Nunier
Contractor Inswance Comnpany/Poliq Number
() 1 am a homeowner performing all the work myself.
• .naenu.e ow a aq of 0*asaeews wo be fa+arad n ow Office A LTM*J an of ew DU.IV evrWare 99vikaiw no an I&AM•Mare
Cowratr Al NOW94 eeew Seaton 2fA of MGL 15 2 can kar w w troop.d- I i eeeseie eefwdnt of a tore of w w41.1100.OD&War eee
+.son•:weeerw m aye at god a wo in doe kma eI a STOP W ORIC ORD ER wo a iw of s 100.00 a on gdiw non
Signed c, `�t day of sn b eR,
:iccrseciFcrmiue Eullding Department
ucensinf Ecare
seleamens Office
^e21th Geparmer�
_. •i::. �.4C : : . - —_eCGC 904 505 405, 77t
PUBLIC PROPERTY DEPARTMENT
+ 120 WASNINaWN VMKST,Sao FLOOR
' SAL04 MA O1 S70
TEL (970)740-MM EXr.390
FAX (079) 740-9640
STANLEYJ. USOVIM JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
la wcardmoe with the previa9ons cf MM c 4q,334 I aclmowlWp dw r a emd dm
of BmIft Permit N .all debru re ukws from the cemmoebou„may
pvanW by Stu Bml ft Patnit d and be diapered of in a peopaly Hocund sohd'wmw
disposal facIbly,as daffloed by MOL c BL Si 13M.
The debris wM be diapered of me No As:d e CAP-t,.v y Pf e ii
Location of Fadhty
Sisoaot<eofPamh ANhow Dab
FULLY ccmplate the follow==mftnaam
PRW CULOL
(PLBASB II Y)
&(-C po
Name OfPe®it
fib, c�IdN ✓ Avps
F=—Nan,%ifany
/ 3 Sew,q [l ;�.
M em,city&State
The above statute m pm that debris dram the daaohticq raiovadon,rehab or other
alteration of bm'Idms or stratum be diapered in a properly-licensed solid-warts diVOW
facility u defined by MOL cA SIMA,and the bundms permits or Heema are to
indreate the locadm of the f c ty.