HomeMy WebLinkAbout1399A -! ---•��---r-__ --.. ._ _. ,. . . � - _� ,__
'�S'C0�1PENSATION PECLARA i:ON �6M444 - S A P P I- � 1—
• �Ea,S,��o, MISCELLANEOU ICATION {`
by affirm that I have a certificnte of consent t�sclf ,. COUNTY OF LOS ANGELES auii.n7Hc nt�n SnrCTY DIVISION
� �or a certificate of W'orkecs'Compensa[ion Inwrance,or t}
�_��rtfied copy thereof(Sec.3800,Lab.C.)
� Poiicy No. Company FOR APPLICANTTO FILL IN wooREss �(o �.QAtvt� ,
� � Certified co is hereb furnished. eu��oiec � �
Py Y AO�RE55 �� LOCALITY O� �a��
N
� Certified copy ic fited x-iih the county bui�ding inspectinn NEMREST /�
department. �ocwurr ��� Cn059 sT. /;C�C GJ�J �/f��� �
Date Applicant NEAREST oisrw�cr rvo. enour �vve rwoccssEe er
cnoss s� .Lp,atJq_ cor+sr. �
CERTIFICATH OF EXE�IPTION FROM1t WORKERS' �Eaa� � • �'—
CORIYFNSATION INSURANCE escrs�rr�orv �ot ruo. �� n�acK ,cHww }
o Mwv �CIaCLE) SYATE MpJOR SECONO LOCAL �
NO.OF BLOGS.
(This section need not be completed if lhe work involved TRNCT �(�J� NOY!ON LOT. ' ose zone sPec�w�eo.�oinows O
by ihe permit is for one hundred dollars (5100)ar Icss.) K—( ,
SIZE OF LOT EXISTING BIDG. ��'1 � �
1 certify Ihat in the performance of the wark far which this �� _
. permit is issued,I shail not employ any person in any manner owruew � �
so as to become subject to the R'orkers'Compensatbn a�vs. r�// /'� OCCUPANCY GROUP V
6��� y+ wooness OY�p v`—�+L'y �' d
Date��!.�,�Applicaat�il..� � / �IC�( V7
� tE�. . z
NOTICE T6 e�.PYLICANT:If,after making ihis Certificate of CITY �.�„rvo. �� OCCUPANT LOAD
Exemption, you should become subjrct to ihe W'orkers' qppLICATION F R � EXITHARDWARE:
Compensation provisions of the Labor Code,you mus[forth-
with comply w�ith sucli pro�isions or �his permit shall be }RPILER use ceo�ocv�nsvecr�orv
deemed reroked. � ❑ NO Spec.Knowl.
LiCENStiD CONTRACTORS DECLARATION OCCVvqNCY INSPECTION Panic Devices ❑
I hereby affirm that[am licensed undcr provisions of Chaptcr 6AFETY PERMIT q (LIST ITEM9 BELOW� ry0.OF EXITS �
9 (commencing with Section 7000)of Division 3 of Ihe 6usi-
ness and Professions Code,and my Iicense is in full force and � /,,,.. ppRKING.
• effect. � � . aeo'o r_� PROVIOLD �
,� SPACLS
License Number LIC.CIJ55 --�
LIMITED TIME USE
Contractor Datc � K o.rE o,..E
� 1 am ezempt from the licensing requirements as I am a
licensed archi[ect or a registered professional enginecr sae oe nb.oF INSPECTOR�3
ncting in my protessional capacity ($ection 7051� IIIIS- ExI3TING HLDG. STORIES siervaTuwe
iness and Professions Code). reESEr�r usE ov eui�eir�e FINAL AP AL
.Sf�v
Lic.or Fteg.No. Date
HOh1H ON'NER•➢UILDGR DECLARAT[ON �o.oF Exisrmc ouno�Hcs � I
ON LOT ANG USE � -
I hereby affirm Ihah I am exempt from the Contractor's � � ,
License Law for the following reason (Section �o3�.s,e�5�- �1 3 4.9 A
ness. ProfessionsCode): gpaPawKixe • • _
CES PROVIOED '��• ��O
1, us owner of the property,will do the w�ork nnd the
structure is not intended or offered for sale (Section '� •+8 0.5 0
7044,Business and Professions Code). � . '
PROPOSED USE OF BU�lO1NG
CONSTRUCTION LISNDING AGGNCY . . . 's[15 0 r�-
, I hereby affirm Ihat thrre is a mnstruction lending agency � r-0
for the performance of ihe work for���h��h this permit is ��2�''—g 6
issued(Sec.3097,Civ.C.).a..i/j�_ • • -
LendePsName lJ vrtovoseo MAX.00C. '
Lender's Address eeRmir ree d,(jv . •
I certify that [have rcad lhis npplication und state that the � . � - ,
above information is wrrect.1 agree to comply with nll County �55UANCE FeE � �
ordinances and State laws reluting to I1111Id1I1g COf15S[IICf10I1� TOTAL FEE "
and herrby authorize representatives of this County to enter �
upon the above•m/f�nt�ion./ed pr e � for inspe t' n p �poses. SEE REVCRSti�OR EXPLANATORY LANGUAGti - � • � � � ' '
�31��5nat^ure oif ��m`4 iTtee � Da[e .
- - -_ - .. .__ y--- - _— —� _ _ _ - -----�- _ - �
t;SV'NFR-I2UILDLG DFCLARAT�N
- , � IN�'VECTOF1':i ROTES ' , ' �
� . . . � ' � ',hcccby affum ttia[I am escmpt frnm dre Con.cacm�a
- � Li:��nu La�.c (or thc (ollo�vinG�cacnn(Scctio�r i031.5.
� - 6urirr_rs and Profrrsions CodeJ' :in�• ci�}� or coiuul'
APPFlOVALS DATE � .��,ti��'ECTOR'`_ . ti'7+ir1+ rCrjr�i�rs a prrriti( !ti [oirelnecf, C!ler,-i:rt��rr���',
� SIGNATVq:� - l�i�tr:nlirlt. nr rrpa:r cnl'sln�ctusc.j�riur rn i1s i.rsuun,c, �
TFtAILER USE � I ' clsc� rcqurrrs tlic o���>lrcc;tf f�r 5:�^�� per+��it fo Ji'c c
.. tigr:rd stalemei�f fl�a; Ae is licerrscd purx��:!u In tl:r
SAFETY PEqP.91T �� i \ ~' � � ' prorr�ionr of tkr Cnntrcrtnri� LicC2rc I.R�i'l�l:.�;�rer S'
TEMPORAFV I - ' � jcor;mcncirr,�i�'rth Srrtion :OOOJ of Uii�rrrr»� �nf tf.�e
S7RUCTURE APPROVED " '' � - G(�Sill.'.SS end fYufr;sinr;s CndcJ or Ihr1 7i,is cscuq�r
TEMPORARV I ' tlicrCfrt�rli or1!I(llC hC.(iS jt�r fft�'all.'A'�'L�e.rc'l.•I?liur:.:11'�'
ST�tUCTUaE n[htoV[o I — ._ . , riafatinn nf Scr(ior; iO3L5 h}'a+?�'r.PP��ccut fnrc p�'ia'u�
. . . � J;iL%rcra'd�c cpplica+if to a crri!prn,alt}�af��o�n:orc tfcc;�
;nr hm,Jrrd dollr�_(c.iOOJ.: �
'. - : I , ��' ' - ❑I.ac oticrcr ot thc propc�t}'�cill do Cic��u:l.,anJ
f
_ . tLe sUuc�urc�s nut intcrdcd or of(crrd fur tal�:.
FINAL APPROVAL � ' ' � � ' �� /See 70-7-i. Burirten'anc Fiafescinr�.c Cude: ll.r Cbr�
, _ �_ .... , Vccinr's'Lire�rtr I,ax'duCs r�o7 appQ�_Io u^. otvie�r nf
. . • - . '" � pioprrrt� Hdw f�arldc i�r in:prorrs ther��ou,onr!�rLo-doe�
, _ �- . . ' , . . ' a��cf: t�•o�l: himcclf �>.•oridcd fl:a1 srrel: iuip�orrmruu�
. . . . Qrc rtof i.�rtersr:rd or ofJi•rrd Jur e�ale. If, lio�rcrrr. lhr
- � Lui;d:n„ or rr�rprorenrcnt ir tolrf �cithirt m:e t�rur n{
cuny;Rliorr. N�^ o��vter�luil:ler i.if( Lm�c die he�dnr
. oJ prori�r, tha7 de Ji;l not build or inrproic Jor tf:v
� ' � p�irposeojsr.le.)
I�m csempt undcr Scc .
_ . . Et Fc P,C.for thi�rc:i�on
� _ .. _ 1Jatc
Oancr
-�
�f INSPFCTOR'S NOTES
/��� . . � — . . �
:�6_l•✓�-� __ _���,
����� , �s
.l_d.�.�s��-c�'� -–��'o��_vcx�. , -
�-��12� ����-�-- . .
�.u�p. l���-�•---/D�� _ '
_._cf�-�-,dL�z�t�s�� ' , . ,
�����. .