HomeMy WebLinkAbout5915WOR KEN W i ONWENSATION DECLARA1 ION
1 herolry affirm fhaA I hVe a catHh" 4 =011t to wif
hNare, w a MEHRmw of Workerd (4rnponsAlon huumme, or
;_: coytifiedoopy 38100, Lab. Cj
Policy NoCompany -
Certified copy is, farroby funhSlicd,
EQdMed copy k Hied x&udh T 11w mnty hudg inspecHan
l depadnim,
Date - ---, -- -- - -Applicant
CERTl1W;ATE OF 1.15M=N !MOM WORKERS'
CONITENSATI(M MSHRANCT,
(This section need not be cornQated if he work involved
by the pemit k Mr ime Andmd doArs I IMP or No.)
I ce.rfifr that fi-, Me p-Rurnam" Of 14 WON Am WMA Ulds
un-rinit is issued, I qjjafl mA onfikq mW pawn I: y nmmor
sO, as to rkers' Con-p-mati) a,,,
fi��f,�nrjo suNcot to the, %sfor en� 1 ( 11 N1
9 - - I I — Applicant
N At TO APPIMANY IQ aly mANg WN COUfleRtc Of
Exemption, you shcodd besmic Adled to M0 V/Ojafs�
C.'onipansation pnwisions of No lakq Codq ymi must fwHi-
with comply U&h mihi pAAAns or thy pwnd 00H he
deemed re AwL
LICENSE,I) CONIRACTORS Df,,(�LARATK)N
Thereby affirm H-au, 1 am aml,.d UMIC-provisionx of Chaptor
9 (wmmm&j wWi SMAn 700M of Divibn 3 of dw BuT
inn and Pmkohn, An, and my lices to in OR fomo and
ofwt,
!Amnse NuAwr LA (An
Datc
I am oxwnlpam !hc flwti,,,�ng requironionts as I ani a
Hconsed ar&HwA or a rtgktercd professional 0119i'letr
actIng in my pvAwsimml uwadty (SmHoui 701, Bw-
iness vital Pro+'Pisionzs Code,',
[Ain or Rug Nm
HONHF,Ofvpl>'l,RAEAIDER 1MOLARA11019
1 y auhm tmt 1 am cam"! Amn % Qwmut&,�,'
Q. . low fin fltv f-oflhovivig, rea�,oni (!Section 7;031-5, Bud -
Has and Prohngms Qde):
as ow cy Hju proputy, Ofl! do o d tc, - h n %.v o, k a -, 1i
Ej Amelmn; I not hMn"d or WTured No, wk (&d5n
7044, Burim ds and Proloskin"vide.),
CONSTRUCT-I,oio LENIDDR,"
GWAY amna tho Moon is a emBbumbn tomidw apency
for tit porPymumo of Mo wmk for whA MN purnit is
Noted (Srun 3091 (A. cj
lander's Name
1wandues Ad&eas
I WAY thatt I ban read WE a"HwOm and Mate, that the
aNwe Wforma1kin i,conwt- I agroc to cornpiy With all CountY
mdMances and swtu Ims wNM, to QHMg smMudban,
aah hpq&AT1 ado rwwwgWm of diredireQunty to Nntci
,t-*
_nl/nEnal Propody hor; , Tc.,rhn purposus.
ign re or Pemain, Data
76M444 7
CV L 575 (1104) MISCELLANEOUS APPICATION ""'
WtjNTY OF LOS ANGELES BUIWING AN[) SAFETY DIVISION
FOR APPLICANIF -T TO F1 LL 1N
'TLY1,01-1,11n: 6Tr�/- e�, SY0 4:e-71--e"fv P,—
E, 0 C A. L ITY
—7, 441el //,7/16,
L80AL
DESCRIPTION 140T NO, BLOCK
T 11-4 A ?-'10 14(2-f lie �Oul ON LOT
=csE of
SUE ov LOr
OWNER
APPLEATON FOR
IRAMOR use El OVOLOGY IN"Mcnom El
OccupA,NcY INSPECTWN E-]
sP,55TY PCRs11T I_] (,,�S-r kTL�ras BELOW)
zoo, / 'nook.
S9ZE OFV NyV OF
VXMUNG BLDG, STORMS
PRESENT USE OF SUMDING
NO, OF 8XMnNG BUH-DMM
ON LOT AND USE
NO. PARMNG
sp-4UES T-Rovico5D
PROPOSED USE OF DOWDING
PROPOSED MAXOCC
PER WT FEE 11c), 6-0
RSSIJAINCE rEle
L, FEE
SEE REVERSE FOR EXM ANXI&ITY LAMRAG '
BUMDHAG P 9C
SAT
R A�C��q
AD 'S 0Y.—T Cj 0
NE AS SIST
CROSS ST,
100-0710 GROUP Yi;�� PRO05"ED By
--, s ---L�
MAP HiGHWAY OB SISCOND LOCAL
STATE MAJ
0 SE A o N-i-oOET s P E� US DiTmNs
OCCUPANCY GROUP
CMCUPANT LOAD
EX7 HARDWARE:
No Spec, Knowl,
PaWc Devices
NO, 05 5XIT'S
PAIIU;l B
PROV
LIMITED TIME USE
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F"IMAL APPROVAL
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