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Home My Public Portal About9412 GIDLEY ST_Miscellaneous__ WORKERS'COMPENSATICIN DECLARATION 7E MISCELLANEOUS APPLICATION v CE 970(11$4) I hesby,at� thaw I have I certificate ofionInsuranc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insar�;'or�ertiflccaa,te of Workers'Compensation Insurance,or a certified copy thmeof(Sea 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN AUIOIX6 wDDRE■/ 941a (pLDLE ST F1Certified copy is hereby furnished. ■u1LDING /1 5-�- LOCALITY ADDR SIBS "7 ❑ department.Ont copy-is�Ed with the county building Inspection LOCALITY .�/T,QJA n/ L /� XS AR SST W✓I rL►?i C..� CROSS ST. Date Applicant NSARE■T ) � DIITR IC7 O 6 TYPE P CSS ■Y CROSS ■T. �C/ CONST. CERTIF'IGATE OF EXEMPTION FROM WORKERS' LZGAL COMPENSATION INSURANCE DS SCRIrTIOM LOT NO. ■LOCK rw Hlo tr.wY no. (Dan ala) STATE MAJOR C LOCAL (This section need not be COm feted if the work Involved TRACT NOW OX LOT■ USE ZONE IBr jCU L CONDITIONS by the pemih is for one h if ($100) or lora.) u■E oilSIZE OF OT SKIS TING EL O. I certify that In the performance of the work for which this o permit is fused, I shall not employ any person In any manner OWNER e'J.4 s') mo as to become subject to the Workars' Compensation Laws MAIL 3 �! t`t A fl` OCCUPANCY GROUP o Date Applicant ADDRESIB �� Lf NOTICE TO APPLICANT: If, after making this Certificate of CITY 60044n.L 3 `�- .�-TJ OCCUPANT LOAD N Exemption,• you should become subject -to the Workers' z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with Comply with such provisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY IXIBrEPanic Devices arloN I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of D on 3 of the Bust ■AF ETY rSRYR (LIST RSY� EEOW) NO. Or EXITS mas and Professions Code,and my license is in full force and lAeo /� �'o L rA RKIX6 RSp'D 1ROVIDSD SrACEf License Number Lia Clan LIMITED TIME USE Contractor Date D wT a DA Ta I am exempt from the licensing requents as I am a rwDrl TOI irem licensed arehtteet or a registered professional engineer SIZE or �--�( Xo. of EcroR'■ NA acting in my professional capacity (Section 7051, Bus- EXISTING ■1-130. 4P l� ■TORIES J ■ Nwru IneaandProfessionsCode). FINAL APPROVAL rR BIBS NT U/S OF ■U10IN6 L.ia or Reg.No. Date HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS 1 � ON OT AND U■S h!•f• `T I hereby affirm that I am exempt from the Contractor's rM4 License Law for the following reason (Section 7031.5, Bust- 7 93.GO mss and Professions Code): No. rARKING �-y� El1, as owner of the property, will do the work and the SPACES PROVIDED 1 ITE structure is not intended or offered for Bale (Section TOTAL 93 -00 7044,Business and Professions Code). DECK �1 �y CONSTRUCTION LENDING AGENCY rROPOSSD USE OF BUILDING DECK 3.00 I hereby affirm that there is a construction lending agency C •00 for the performance of the work for which this permit is Issued(Sea 3097,Civ.Q. Lender's Name PROrO/ED MAX. OCC. 1 6/29f Wi Lender's Address 1`79 1 W114: 367 certify tify that I have read this application and state that'the P)rRMIT vas above information is correct I agree to comply with all County IeauANCE Ras ordfmnces and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FSE upon the abovo-mentioned Pty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 1 turn of ee Date WORKERS'COMPENSATION DECLARATION CE 876 (11-84) MISCELLANEOUS APPLICATION ^- CE 876 1 hereby afTi m that I have a certificate of consent to sett COUNTY-OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Worker&'Compensation Insurance,or a certifkd copy thereof(Sec. 3800,Lab.Q. Policy No. Company Rf"Li4 ;44' FOR APPLICANT TO FILL IN ■U,LDING pwc�/- =ty AD DR[1f RCertifled copy is hereby furnished- ■uILDINa y/Z if-SOL6c r sr LOCALITY _ Certified copy Is filed with the county building inspection LOCALITY EMP N[AR■fT department. 3�C T l.� GZTr 6v4. 1790 cRof■ ■T. Date Applicant M[AR[fTT HQ. aR0 TYP[ �R [[f[D ■Y CROSS ST. �,NrLIg GZTY 1-7 LVf� D d(J CON CERTIFICATE ICATE OF EXEMPTION FROM WORKERS' L[aAL f COMPENSATION INSURANCE D[SCRIPTION LOT NO, ■LOCK NO. (CIw CLL) STAT[ MAJOR ■[GOND LOCAL p y NO. OF ■LDGS. (Tills section need not be completed If the worst involved TRACT Z /7/ NOW ON LOT S_ Uff ZON[ fr[CIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) ufe OF /// SIZ[ OF LOT 4 Y 000 [AIS TING ■1-136. / �� I certify that in the pperformance of the work for which this p,. permit is issued, I shall not employ any person In any manners o.N[R of buil ding $O$ 6iG�,S c� J TAI as In hcnnne sul>jeet to the Workers' Compensation Laws. OCCUPANCY GROUP o: MAIL 9y/y 65,13 Y T AD DR[ff 1-.G rT• r- Dale Applicant u, NOTICE TO APPLICANT: If, after making this Certificate of crrY T�j�y�j,Q (� rTio� 5►r�(� OCCUPANT LOAD �� Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be rAAILCR Uf[ E] G[OLoaY INfP[CTION EJNo Spec. Knowl. decined revoked. I I('ENSED('ONTRA("FORS DECLARATION OCCUPANCY INfP[CTION ❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter SAFK-Y PCRswrr ❑ (LIST 1reM■ ■[LOW) 9 (commencing with Section 7000) of Division 3 of the Bus- NO. OF axITS ness and Professions Code, and my license is In full force 'nix Name of business XP AC I R[a'D PROVID[D O SPA C[■ Licence Number y�g273 l.lc- Class 8� 8 YGE P,4XIC6 - &dJ*P�y LIMITED TIME USE Contractor A. J_ —__ Dale y—/k-97 DwT■ DA rt I am exempt from the licensing requirements as I am a Pwo NI TO licensed architect or a registered professional engineer aIN ATO R'S acting In my professional capacity (Section 7051, Bus- [x:IrTINaeof ■LDS. vaeo so. FT No. or frowle ls / bees:and Professions Code). PRca[NT us[ of ]BUILDING FINAL APPROVAL 641�_1 -11 I.ic.or Rcit.No. . __. DateO HOME OWNER-RUILDER DECLARATION No. OF [XISTINa■UILDIN°■ 0 Lor AND uf[ '?167 1 PM ,•'Ft',`, I hereby alTirm that I am exempt from the Contractor's S License law for the following reason (Section 70315, Busi ness and Professions Code): NO. PARRINa El 1, as owner of the properly, will do the work and the 5PAC[8 PROVIDCD structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUC-PION LENDING AGENCY PRorofcD uf[ of ■u1LDINa 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is iuued(Sm 3097,Civ.C.). Lender's Name ____� PROPof[D YAA. OCC. Lender'sAddresS_.____ _ _ . 25 . 00 I certify that I have read this application and stale trier the PERMIT FRE above Informalulrr Is correct. I agree to comply with all County IesUANC[ F[[ ordhiances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL F[[ 25 .00 upon the above-mentioned property for Inspectlon purposes i SEE REVERSE FOR EXPLANATORY LANGUAGE WORK�jS'COMPENSATION DECLARATION 444 76M 4 CE 675 (11-84) MISCELLANEOUS APPLICATION I hereby aEcor th4t I have a certificate of consent e ,elf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insare a¢ a certJflc$te of Workers'Compensation Insurance,or a cart�f}od copy diereo:f+(Ser– 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN ■uILD INC SO Certified Certified copy is hereby furnished wo Dw i.: 9�+12`GIDILEY ST. LO CA LrTY Certified Copy is$led with the County building inspection Lo a w L IT Y TEMPLE CITY . N[w R[/r department. y��Ty CRO■■ /T. Date Applicant -.AR[/T TEMPLE CITYAVE. DI■TR ICT XQ. Ur ITYPIC / [//[D BY CR06■ WT. ��LL ' ^ �/ _�J COMET. 'J CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE —DESCRIPTION LOT NO. ■LOCK —1 HIGHWAY Ho. (CIRCL/) ■rwT[ MAJOR /steno LOCAL NO. Or ■LDC/. (This Section need not be completed if the worm invotred TRACT NO oX LOr u/[ sons ■r[clwL aoNDrrloris by the permit is for one hundred dollars (;100) or len.) us[ OF I certify that in the performance of the work for which this •II[ OF LOT EXISTING BLDG.-D4, LD 6. O permit Is issued, I shall not employ any person in any manner o.N[R bae-T b i G r s, so as to become subject to the Worker- Compensation Laws. I L3 MAIL `, OCCUPANCY GROUP o Date Applicant wDDR[// T[L. OCCUPANT LOAD °- NOTICE TO APPLICANT: If, after malctag this Certffloate of aIT Xo, a� Exemption, you should become subject to the Workers' - z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall beNo Spec. Knowl. deemed revoked. rRwILSR u/[ G[oLoav IX/r[ar1oX LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION [ Panic Devices I hereby affirm that I am licensed under rovisions of Chapter 9 (cowmen with Section 7000) of D g SAFETY }[KNIT (LIST IT[Y/ [[LOi� n 3 of the usi- NO. OR [xlT/ nese and Profession Code,and my license Is in full force and effect. PARKING /PAC[/ R[q'D PIROVIDKD License Number Lia Class LIMITED TIME USE Contractor Date o AT/ DA Ts I am exempt from the lid requirements as I am a rRD�I TDI licensed architect or a registered profbWonal engineer /Is[ Or Xo, or IX■raarOR'■ acting in my professional Capacity (Section 7051, Bus- [7[1■TING BLDG.6. STORIES sf6 TUR[ fmsaand Professions Code)' PRESENT us[ or BUILDING P'INAL APPROVAL Lia or Reg.No. Date / s HOME OWNER-BUILDER DECLARATION NO. Or [XI/TING BUILDINGS ON LOT AND U-S[ D /� I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Burl- nose and Professions Code): NO. PARKING I, as owner of the property, will do the work and the ■rwa[/ r[ovlb[D •ti structure Is not Intended.or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PRQrO■[D U/[ OF ■UILDIri6 I hereby affirm that there is a construction lending agency NiANiTFAC= CAB for the performance.of the work for which this permit Is ec. Issued(S 3097,Civ.C.). Lender's Name rROPO/[D YAX. OCC. Lender's Address -[KNIT refs I omtify that I have read this application and state that the above information is correct.I agree to comply with all County fesuwnc[ Ps[ ordinance, and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL F[R 00 uponabove-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 17 Signature of Permittee Data