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��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 �„ �
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