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HomeMy WebLinkAbout0929A (5) woRxexs�coti��FNsnT�oNr�Eci.�anrioN �sMaan MISCELLANEOUS APPLICATION CE 875(2-80) � � hz�eny r�s+�m that � nave a cer�it��atr or co��sEn� to s��r COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure.or a :,�rtifica[e nf Wurkers'Compensation Insurance,ur a cErtified_1DY thereof(Sec.3800,Lah.C.) �� Falicy Nn. Cumpuny FOR APPLICANT TO FILL IN �pwess �z 2 i � c�.L �fi � Certified eopy is herefiy furnished. eu��oirvc "1 'l ]� / /T AoewurY �t HDORE55 rt,/�r L.. � L,i � � Certified copy is filed wi[h the coun[y building inspection �oew��rr �+EAREsr � � department. 04tGI �35�_.�' ewosssr. � � C�/'f�.� Ua[e Applicant NEliREST _ � /) 1. o�sre�er rvo. ceouv vve Y ssEo av —W�. C.�11[.ciC- ' oHsr. CERT[FICATE OP F.rk'.MYTION PROM WORKERS' oescrsiPT�o� . ^��/ �ocK ��Hwa j� COMPGN5.4TION INSURANCE a �` — � ��� �E� srwre MAJOR secorvo�ocw� d (This section need not be completed if the work involved 3 �I now o��or 5� � use zorv srecia�co�o�noNs O by the permit is for one hundred dollazs ($100) or lessJ usE oF �ZE OF L � EX�STING BLDG. Q I certity Ihat in tho performence of the work for which this � �� O permit is issued,I shell not employ any person in any manner ow�ER r - Ij'r'� � V so as to become nubjec�to the Worker�'Compeneation Laws. Mp�� OCCUPANCY GRDUP W qO�RE55$G( � Ua[e Applicant � NO"CICF'70.4F'YLICANT:If,af[er making this C'ertiticate of eirr rvo� OCCUPANT LOAD ? Eaemption, you should becnme suhject to the �b'arkers' - qppLICATION FOR EXIT HARDWAFE: Compensn[ion provisions of[he LaUor Code,you mus[for[h- with compty with such provisions or this permit shail be TRNILEN use� GEOLOG�'i�srecnoN� No$peC.Knowl. ❑ deemed revoked. ❑ LICtiVSEU CONTRACTORS DF.CLARATION OCCIIPANCY INSPECTION Panic Devices 1 hereNy aTfirm[hat I um licensed unJer provisions of Chu�+ter I SAFETV o miT q (usr i�ems ee�owl � 9 (commencing with Section 7000)of Division 3 ut the Busi- �a.or exirs ness and Nrofessions Code,and mv license is in full force and � - Z{frl't. � wCESG� REO�O � PROv1�Eo LicenFe Number i.ic.Class LIMITED TIME USE Contcactor llate o.rE � 1 am eaempt frnm [he licensing reyuirements as[am a licensed arcAitect or a registered professional engineer rze ow sre roa's ac[in6 �n my prnf�ssional capacity (Section 7057� f]IlS- EXISTIN6 e�oe. sroa es r sic wruse iness and I'rofessions Code). raeservr use oF eu��o�rvo FINAL APPROV AL�r,/ y� '.I�, Lic.or Reg.No. Date — � �� HOME OW'NF'.R-BUII.DER ntiCLARA710N oF xi�srirvc eu��oirvcs �or w use I herehy affirm [hat I am cxemp[ from tha Contractor's �.��e�,s� �a�� e�,<<nr r�uow;�x�ea,��, �se�it�» 7o3�.s, a�s;- �0 9 2 9 A ness end Professiuns Code): �� � � �3� � I, as owner of the propert7,will do the work and the s«��r��e �5 �or ���e�eea o� �rr��ea e�� sa�e �s��c��� I . •8 1,0 0 7044,Busines.c and Vrnfessi�>ns C'od�). pRorosEo use oF eui�o�rvc • o :;i.Uli� COKSTRUCTION LFND[NG AGIiNCY i n���ny ,,rr��m �i„i rnz.r �s �cunso-ucr�o��end����Ke�,�y 0�,2 4—8 5 for the perfn�mance �f the �+�ork for which [his perinit is issued(Szc.3097.Civ.C.). . Lender's Name rwoPoseo m . . LCIIISCI'�5?�AdtC]) PERMIT FEE 7D�•� I�ectify [ha[ f huve read this upplicati�in nnd sta[c thut the ab�e inPo[mation is e�t.I agr�t to cortlply�vith�II CountV �SSUANCE FEE /Q�S-� o�d� ailt'e�}:fn� S 'lawc atin� [� luilding C<�h5t��cfiOn. TpTAL FEE 8/rQ� a hereb� auth �z re �e tnCives nf thi. County to entar u n the�buve- ed p perty Sor i pec[' rpo� SF:E REVERSE I°OR EXPLAN9TORY LANGUAGE , � SiKnacure uf Permittee Date .__ '____..._.__...._�__._.... �.^+..'JP'.t< 4{.��'�IlE.it I):-(I \{�'.\I I:-�+ INSPECTOR'S Ni;TE; .___.. _.._.�___.__-__..___.'-___ - _.... _._ . . _ _ . .:ir:�„ . !an, �� :j���:r.-u� .' :.ir.;,,..:�. , __ .._ . __ ._ ..__ . . _ _.__. .. . _..._ _. . ._.. ..��. . '��; .Lo �-liu��i.. r a.:;:. r.� �.;�.� :��;_;. - . . . .. . .. -. ,:�� nPpr�:���.�qLs „/llp �SrE ?UR'[5 '—_---- --- --_.�_._..—. �r: ,. I: �. . tJ ��iN� .�JNE ._�,� . , �_� (fltl Stl't!i i ,:�Ylr!Y f i�- �Sf���lt�.','. _.__—T—..�—_---_.'.--_ . 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