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HomeMy WebLinkAbout1656 _:_�� ��oa��:as•�o����ENSAT10NU4:CLARATION 7ennaaa MISCELLANEOUS APPLICATION {� CE 875(2�80) � ��rre�y att�rin t���t � ��a��� � �rr��r���te o[co�sent to:��r COUNTY OF LOS ANG�LES QUILDING AND SAFE DIVISION �� insure,ot a certificate of R'urkers'Compensation Insurance,nr a certified copy[hereof(Sac.3800,L�b.C.) � I I'ulicy No. --Compan�� u FOR APPLICANTTO FILL IN nuuoi�o C ' • � AODxfisS a��O • ❑ Ceriitizd capy ii htrohy furnishcJ. u��o��� �,f� � LOCqL1TY �, �'�[� �� ADDRESS�T � Cn1Gi�✓� 2 . �I� -'�+ � Certified cupy u tiled with Ihe county buiiding inspection � � NEAREST y � � Jepartment. � �oewurr r ��n�uN��2� aC I/� ewoss sT. 1 Ua�e a�)PIIC:1f1I NEARLSi ^ DISTRICT NO. ROUP TYPE PROCESSEU BY cwoss sr. /:L SOL \p �2 co Q\O � CGNTIPICATE bP GXL�IPTION FKO?t WOItKL�:ktS' ��ca� [} 1 � COAINENSATIO�I IYSUR.INCE oEscn�PT�orv �or No. )(� PLOCK Hw� NO�,��� ��CInCLEJ STATE MAIOR SECON�LO�AI Q, �7�3 3 NO.OF BLOGS. Q (TLis section need nut 6e compluted if ihe w�ork incolved � TRwcr NOW ON LOT use oHc SPECINL CONOITIONS by tLe permi[ is Cw one hundred dollus ($100) ur IcssJ usc oF ��� �) . s�z�oF�or exisrinc s�oc. (j� � I certify tha[ in Ihe perfonnznce of�hc work for which this . lo � pennit is issued,1 shall m[em lo'an erson in any manuer ownex v > r v L' �lDi_i2 - H 2_ ,✓ V su•5 V1�become subject to U�/e\Sorker'!'umpensation Laws. Mp�� L � � OCCUPANCY GROUP � - W J{(ill�6t2._ PP 1�d�A� wooaessS�J./�� Gi✓eiNolJ� a uacc w. lican� . , . N �s�./`= p Z NO!I�,G 7O APPLIGNT:If,after making�I�is C�tificute uf CITY µrnau�A2 e+o.�j 7J"7 7 a j OCCUPANT LOAD Gxemption, yuu should becume subjtct to the 14orkeri T APPLICATIONFOR EXITHARDWARE: Compensation provisiuns of the Labur Cude,yuu inust forth- �Y11�1 COIII�)�}' N'jl�l SUC�I Provisions Il� (h15 ptrnit SII;III Il< - TRAILER USE� GCOLOGY INSVECTION� � No Spec.Knowl. ❑ lj2CIf1Cl�fl'�'(1{:C,. " � L[C1iNSLU COKTRACTOKS DECLARATION oeeuvaNer wsecerion � P8f1�C DBVIC25 ❑ � 1 hereby aifirm ihut 1 am lice�ucd undcr provisions uf ChaV�zr SAFETY PEaMIT� �LIST IT6�f5 aELOW� � ry0.OP EXRS a r 9 (cummenCing with Ste[ion 7000)uf�icisiun 3 of the Busi� � � , . ness and Yrufessions Cude,and my license is in full force and ? vpRKING• effect. ` • Reo'o � PROYI�EO � ' SPACES � License Number Lic.Cl�ss K LIMITED TIME USE (.OI1IfJCfU! �Jt2 . uwte owTe ' � 1 am exempt lrum[he licensi:tg re4uiremm�is as I am a � lieensed archilecl �� � «6�stereJ professional engineer .izE oF rvo.oF �NSPECTOH�S ' aciing in my prafessiunal capacity (Section OOSI, QIIS- EXISTING o�oe. sronies SIGNATUn6 . inessana ProfessionsCode). rwEscrvr usc ov euuo�He � FINAL APPROVAL p � /_ . //� Lic.ut Reg.No.� Ua�e L S� ,�N�'/ L y �/{�%1(.{�� HOAIE OR'NGIL-BUILDIR UISCI.AItAT10N �o.or--exisnrvc euao�rvcs ON LOT AND U�C I hereb3' af(irm Ihoh I am exemp[ from [h2 Cuntractuts � � , License Law for tLe fullowing reawn (Sectiun 70J1.5, l3usi- pqaHir+e � ness and Professions CoJe): snaees vwavipEo - 1, as awner of�he prnpert5'.�+�ill do the work��nd thc structure is nu� intendeJ or offarcJ (ut sale (Sectiun � — �- 7034,Businzss and Yrufessions Codc). � - . PfiCr03E - a+4LiqG CONSTRUCTION LIiN�ING�GGNCY .h1 j/tl CO✓l�/C " � 1 herebY affinn that there is a consUuetion IenJing ugency for the V�r(ormance of the u•ork fur �d�ich [his permit is �- C � (. . issued(Sec.3097,Civ.C.). I�70 O✓FT � . . . �(p�j'(s.. ,•x� LrI1tICf�S NllI11C PNOPOSEO MNX.OCC. � i'�� LrfldCf'SA�JfI'S5_ � PERMITFEE 4 1 certifY that I have rcad �his applicafion and s�ate tliat/he • � ' ` •,��.a0 abnve infonnation is cuuect.i agree�O COf(IV�Y«���II 8II COU���y �SSUANCE FEE Uldinances and Sta[e Ia�vs relu[ing [o builJing construction, � � ' G�•�0 and hereby�utlrorizt rcprcsenlatiecs of this CU�flfy fD CI1IC! TOTAL FEE upo� the above�menti�^re�' ,�operry fur inspectiun urposes. i SGG 2BVERSF,PUR EXPLANATOI2Y LANGUAGE . . - Ip I r00 �,(,�/`1 Signeturc of Permittee• Y �„ � ` . . . _ . -._ _ _. _-_._�� . r. . e �c e, � '� �, c:�.- e,- .. .. . . 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