HomeMy WebLinkAbout1429A (8) "v��F'zs'�°'°r�ENs^TI°h°F�''"R''T'°"" '6"'°"° MlSCELLANEOUS APPLICATION �
�CE 875{z-60)
I hereby affirm that I have a certificate oe consent(to se�e ' COUNTY OF LAS ANGELES BUILDING AIVD SAFETY DIVISION
insure,or a�cestificate of Workers'Compensation Insur¢�nce,or
a egrtified copy 2hereof(Sec.3800,Lab.C.) �
BUILOING .y � �
� Policy No. Company POR APPLICANT TO FILL IN Annwess �`2.3 3 / �
� � Certified copy is hereby fumished. s���e��� �ocwurr �
anDnESS ZZ337 Broken Twi
� Certified copy is filed with the coun[y building inspze[ion �OCAI.IT}' NEAREST
department. Dlamond BaP ersoss sr.
Date Applicant ��ae�sr oisrrt�c r+o. c o ocessen er
CR095�r. Diamond Bar & Pathfinder �p �'3 �s*.
CERI'IF'ICATE OF EXF,�IPT[ON GROn4 WORKERS' �E6w�
COMYENSATION INSURANCE DESCFIPTION LDT NO. BLOC% � tn4v ��..w. }
(c.Rc�s� srere mwion s carvo�ocw� �y
ND.OF 6LDG3.
('Fhis section nced nof be completed i[the work involved rawcr 30099 now orv�or �NE use zone sPeuw�cono�no�s 0 .
by the pe:mit is fox one hundred doltazs(5100)or tesaJ
USE OF
size oF�or 95 650 ExreriHc e�oc. e 1 �
I certify Ihat in the performance of the work for which this � O
permit is issued,I shall mt employ any person in any manner OWNER CAPITAL BANK �
so as to become subject to the Workers'Compensation Laws. Mp�� OCCUPANCY GROUP� W
Date Applican[ •�°aE�s 111D1 La Reina Avenue N
NOT[CE TO APPWCANT:If,after making this Certificate of c�rr powne � C�Q �o`.'213-923-4526 �CCUPAN7 LOA� �
Exemp[ion, you should become subject to the Workers' � qpp��CATIONFOR EXITHARDWAflE:
Compensation Drovisions of the Labor Code,you must forth�
with cumply with such provisions or this permit sha0 be TRAILER use� GEOLOGY�nsvEcr�orv� No Spec.Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARRiION o«uP�N�.msPecnoN , Panic Devices ❑
I hereby affirm that I nm]icensed under provisions of ChaD�e� BAFETY PEwMIT[� I��sr ITEMS ae�owl No.oF sxirs �
9 (commencing wi[h Seetio�7000)of DivisCon 3 of the BusL
ness and Professions Code.and my license is in full force anQ PARKfNG• �
effect. u � srwces ' "Eo'a � PRovmeo �
License Number Lic.Class
LIMITED T{ME USE
Contrflctor Date owre owre
� I am ezempt from[he licensing requirements ns I am a�.
licensed arehitect o e registered professional engineer s�ze oF � o,or ��s ecroa's
acting in my professional capacity (Seetion �OS1� Bll3- EXISTING e�ee. srors�Es r 4� wtruwE
inessand ProfessionsCode). rnEse��use oF auao�rvc P'�NAL APPROVAL --y
Lic.or Reg.No. Date �
!P
HO:vIE OWNER-BUILDkR DECLARATION NO.OF EXISTING sui�o��vag -
on�ot wwo use
I hereby affirm thab I am ezempt from the Contractor's
License Lxw for[he folbwing reason(Section 7031.5� BII51- NO.PARKING
neas and Professions Code):
SPAC£S PROYIOEO
� I, as ow•ner of the property,wil]do the work�nd Ihe �1 �a 2 9 A
structure is not intended or uffered for sale (Section �+• • • �3 O
7044,Business and Professions Code). rrsaPoseo use oP suuninG � •���Q.S�
CONSTRUCTION LENDING AGENCY • • •�G 5 O CYi
I here6Y afCirm tha[ [here is a wnstructiun lending age�cy D x 0 9—8 7
for the performance af the work far ]iich this permi2 is
issued(Sec.3097,Civ.C.).
Lender's Name pROP05£O MAX.000. �
Lender's Address pERMIT FEE O�O"� .
I certify that I have read this aDP���a[ion and state that[he �55UANCE FEE (��
above information is correct.I agcee to comply with all CountY d�J " �
ordin, e and Sta[e Inws relating�to building cons[ruction, soTw�Fee �
and es y �uth r rese atives of this County to enter Q•
up i e av r � � ned �„�fns...dnspectio p � oses. SEE REVERSE GOR EXPLANATORY LANGUAGE
Sig ature o Yeu i T a
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