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HomeMy WebLinkAbout1369A Nf('?iKliRS'COA�IPLNSATtO'VDt(:LARATIOh 76M444 p�pC�^�g 1 p Rlc�R !� A[9�1 �,wpTl�wO � CE875(280) 171A 76� L`.C�AMG. 6.D r" L \.0l'11 1 itl � i�ereey aef:�m that � ha��e a cert�Ficare oF conscnt vo se�t CE?U1V3'Y OF d,€3S ANGEY.�S E3UILDING AND$AFETY DIVISION `'� insure,or a certificxte ot R'orkers'Compensation Inswance,ur a cer[ified copy thereof(Sec.9800.I,v6.C.) ���///JJJ /� � Policy No. Company �ppp APPLICANTTO FILL IN A�ORE55 ` � /VV�'Y�v � Certified copy is hereby furnishzd. eui�o�rv � —� ❑ ADDR£55 C� .. ,• LOCALITv �. J�F Certified copp is fi]ed with the county uuilding inspeetton elepurtment. �new��rr�/f� �.s e� � �„I �pOREs'�'. !z E� ss NEAREST � �� Date .4pplicant �'J/a� gy."..��,��C;% �srn�cr�o. RouP ��E� PROCESSEO sv ST. , �_r r S $ � s CL:RTII'[CAT'E OI'liXE[.7P7[ON FR0�4 14'ORKERS CO�IPL•NSATIO�.�'[NSURdNCl DESGRIPTION . g�Ocic „p a BLOGS. (cc �E-) SiATE MAJOR SE OND L (This section need not be comgleted if the wo�k im�olved osE zoHE P ,. oMo�r�o�s � � by [he permit is for one hundred dollazs (5160) ox lesc.) usE o - izE oF:.o: Ex�s rv�e�oc. � I certify [ha[in the perfnrmance f't e o foc�vlii Iiis i ' permit is issued.I xhall no[empl� � e on in� mannar wrvea y7 � ����� � U so as to beco e s �ect to the\� ' o nsa.ion La�vs. p�� ,�^�_ ��a OCCUPANCY GROUP y� Uate/�y��pplicant _ a�oaess��..'� �' .c'�f�� 7`+.��� � ;r� ,�tf ..� �f E�.�:'� / �S��°a-' z N07iCE"O.4PPI.ICAb:. ' T, king this Certificate of �/ mo. OCCUPANT LOAD Exemp[ion. pou shou� b �m �ubject to the R'orkers� Com�ensation pruvisions Uie Labor Code,you musi forth- �PPLICATION FOR EXIT HARDWARE: with comply with such proeisions or t}�i� permit shall be 7RA:�ER V GGOLOGv irvsPecrwrv dcamed revoked. sE� ❑ No Spec.KnawL � LICtinSF:D COVTR.aCTORS D2�:CLARA"C;On OCCUPANCYINSPECYlON Panic Devices ❑ � I hzreby affirm tha[I am litensed undcr provis:ons of CBa�ter swFexv PERm:r� �usr ITEMS BEIOW� Np.OF ex�rs �' 9 (enmmeneing with SecYion^000)of Uivision 3 0:the Busi- . � uess and Nrofcssions Code.and my licens�is in full force und • — — � L't�Fel;i. �•� / SPACE56� REG�O � PROVIOED �� License Kumber�L•,c.Class ��_— . -: � � ---"'! l� /r_ / ,�^�^� / LIMITED TiME ,USE Cuntractor��1�.+�CT' Uxt� I�CJ.� �G��.�,8 G OIKIVu`�T� ��oo`M d � oAre owre � I um exem t from [he 7icensin� e uirements as I am a 0��4 1 P b�4 L (�1M'YIGS'� ^ 1��SI �GVaL Y(1N INSPECTOR�S� licensed architect or a registered pro£essional eny+ineer size oF d���gty� L„ mo.oF - ' acting in mq professional �apaci[�- (Section 7051, Bus- �sr�nc sLoc sToa�Es SIGNASURE : iressundProfessionsCnde). —� /y FWALAPPROVAL � PHESENT USE OF BU]LOING q' ��'A-�-3���fij �--F`^-��` ��-�Y� Lia or Aeg.A"o. Date _2s F�ew oa��.�.. _ _ , HO�]L OWNER-Bl:ILDL'R DI:CL:ll2A7IUV "'o.oF EN�o u�rv£OOILDINGS � ON LOT 0. I hereby affirm th�t�I um exemp[ from ehe Confractor's License La�v foc the follow�ing rexson (Seciion 7031.5, Busi- � 3�� ness and ProfeRsions Code): sewcEs v � 1, us owner of[he property,wi1L do the woek and [hc �m m 3� s�r�cture is not in[endad or offered for sale (S�ction � 7044,Ausines;and Professions Code). Faorosen use ov eu��o�rvc � �' m C�,lnn�(� CONSTI2L'CTION L]�:NDING.4GI?:VCV' �vc���,z I hereby affinn thsst [here is ss construction Ienaing agency � � for [he performance of the wurk for wh�ch [his perr.:it is U',.� 6�E,r� issued(Sec.3097.Civ.C.). Lender's Nante PROPOSEO MA%.OCC. Lender'sAddress PERMITFEE II (�'� I cer[ify that I have reud this applicucion and stvte tha[ [he abo��e informsst" is curr ct(agree to comply wi[h ull County �ssuwrvce FEE � � ordinance: an St tc �cs relating To building coustruu[ion, Tora�Fee �—�y� and hera y � h i- mpresent�tises oP chis County to enter ��V [f upon th a � [ioned property For insj�ec[ion purposes. SLL kEVERSh�FOR HXYLANA'IOR1'L LNGti.aGE �- f `/ -��� gn. e Uate � � S310N S,HOi��dSV; � -----------------------_—.--' "'--,_._ ,.-_,�..,��.�_.....__..._.._...__.�.._-_._...�._-_-___-_..._...... �.S"ZaY� ..._._.....e�_.._._,____....a._..___,........_... ... ,.._.saa.�,p .. . — ---'. ;:., :.;• .._, . ,.... . . - ._�.._,.�....__._--_.__ ____ �_ .......,..._..--a e � , E Li _ _::..r::_�_._:_��__..,.�.:�_ -,... � ,. . ... � , ' ��'� .._.........�,�__._..__.� _. . - . ,.c_.,� ,, �' �., . ..-_ ....- -..._ __ � .. -' _ .... _..., - ___ -7' ' _ ' � �/ /. 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