HomeMy WebLinkAbout1718A u'012KERS'CO�iPI'.VS.aTfO�U};CC.4RATIOY �gp'642D APPLICATION FOR PERMIT {�
CE 809(7�80)
I herrhy affirm that 1 6avn a,«rtificate of cnnsent tn self SEW ER-SEW�AGE DISPOSAL ��
insure,or a certificate olµ'orkers'Compensation Insura ,or
s certified copy there�f(Sec.3800, C.) COUNTY OF LOS ANGELES BUIL�ING AND SAFETY
Policv �.��o�p�� '
�� FOR APPLIC T TO FI L IN CONNECTION DATA
� Ccrtifia copy is tm S'f rnished. L `l
lUILDING �/� lT11TION /S�rv� G6PTM /J 1� .
� Certif'ed cn y is filed wilh the tt�un�}•bu' ing' spe in �DDNE66 /// • / -
de n. � +-�� M1INNOLE RCFER6NCE
oc�urr �nan
Uate IicBn1� . s�'Z'�' K� wsw
VP N6�1R6lT ♦r�H OF CONN6CT L6NGTN FROM, �
C.RTII CATE OF EXEMPTI M1 FROM W'OHKERS' �Ross 6r. r. cuwe �.�. w.�,ro�.�,+:�
COMYEf�S.4T10N INSURANCF, •.c.no. /
OMIN6R , CO.IM�,HO. JO!NO. �3 S�'�
�Th15 SCl'�IOII 11!!d 110� �1! CORIp�C�C'd if the WOI�C IIIVO�Vfd 11DDREl6 T11VMK�6RMIT NO. R011D�6RMIi 110. a
by [he pertnit is for one hundred dollart (SI00)or Icss.) .,,o.,,, ,,,,,�„ �,,.,,,,,,,,e�o.o.�..,...o. o.,� p
CITY TEL.NO. U
1 certity that in �he performence of the w•ork for which this �so�� _ / '
permif is issued,1 vhell nn[empiuy any perwn in any mennet oeacw�rnow tpr wo, �p �-1 wwr.aw LT.M106NING �
xo ax tn becomr subject m the Workers'Compensa�iun Laws. F
�LOCK TR11CT � / 3T11T6 6NCROIIGMM6NT
1)ulc �pplitant tio.or s�cos, ► MIT ND. W
NnTiCF.TU APYf.]C.�NT:It,after meking this Certificale<�f BISE OF LOT How oN�o� y ��� �r Z� O�G� �
k:xemytion, you shoulJ becnme subjeq to the Workerti' �se oF N
Cnmpensa[ion provisions ot the Labor Cude,you must forth• Bu��oines CwARGE6 �
with c�mply with such provisions or this permif xhall hr '� CONNECTION CMIIRGE iEE '
deemeJ revoked. conrn�cron
LICEtvSEU CONTRACTnRS UtiCI.AR.4TiON 1�OD�BBB � � J MC�MBYR6EM6NT F66
I hemhy afPirm that 1 am licensed under pruvisionsofChaDter p G .*�,e,.o. cwo� .... ..oao..
9 (commencing a�ith Section 7000)of Divicion 3 of the Nusi- nrr �, re�.wo; �, p eK •c
naa and F'rofassinn5 Code,and my license is in full force and °T• e �f� S'G L°• � �� �1 �'�- �'� �/,c.i-ti�
C((CCI. L�CENSE rv0. y� cucc ✓
no. OE9CR�PTION OF WORK FEE
Litense Number Lic.Class L r�f��o��e�r��c ro C�,J DATE 3 ,3 �o�' VALIDATION
� ., .�. e.
Cnntractnr Date� �*�+oio�'o FINAL
� i am ezempf from ihe licensing rryuirements ax I am a ` op
IicenseJ architrct or a rcgictered profeuionel engineer
acting in my pmfssaiunal capaciU� (Sec�ion 7051, Bus-
iness and Yrofecvonx Codc). eV�i
I,it.�x Reg.:vn. Da[e
110'.7F:()N'N}:IL�BUII.UF.R UECL.aR.�TIO'.J �+� '�� a��
I herrby affirm Ihat I am erempt from the Contractnr'x OWNER�$ Permit f S�� f�,• • • • � �
Lirenst I,uw Gx ihc Follow�ing reason (Sectinn '031.5, Busi- AUTH�RIZATIQN TOTAL FEE oT� Jl(,j �'• •2 2 Jr�
nesx anA Professions Cnde): � • •�2.Je O J
� 1, ea ow•ner of lhe propar�Y.w�ill Jn llie w�ork anJ the *o.�c vv.��c•.w.w. °•�o�e ocscw�.. 0 a 0 3-8 2
suucture ix not intendeJ or nffered for xalr (Srction SIGNEO THIS owv oF n
7044,pusinrss�nJ Professions Ccxlr). —
CONSTRUCTION I.IiNDINC AGI;!�CY �i��•�i
1 here6y affirm that lhere is a construc�ion lendin�agency
for the performancr nf the w�urk for uhich Ihis permit is ,
issued(Sec.J09',Cic.C.).
Lender's Name
Lender's rldJrcss
1 rorlify tl�at 1 havr m��d lhi5 apDlication and 5tnic that Ihc
abm'e informalion ix enrrect.1 agrer tu comply w�ith all Cum:ty
�rdinanccs and Statr IAN'S regulaling�mhing and SeN�rrs,
anJ hrrrFy aulhori�c representa[ivesl f his Cuunty[o eNer
upnn the abuvr-i iune p7oprna•for i speclion puryos�s.
/ SEE RF:Vp,RSE FOR EXPLANATOItY LANGUA(:ti
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