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Home My Public Portal About9414 GIDLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M ISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS FICertified copy is hereby furnished. BUILDING ADDRESS LOCALITY ,e 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP (HI G NO. (CIRCLE)NAY STATE MAJOR SECOND LOCAL CIR NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of > T certify that in the performance of the work for which this SIZE of Lor EXISTING BLDG. � permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP LL MAIL Date ADDRESS Applicant a TEL' OCCUPANT LOAD tr NOTICE TO APPLICANT: If, after making this Certificate of CITY No. o Exemption, you should become subject to the Workers' °- Compensation provisions of the Labor Code, you must forth- AP.3-41ATION FOR EXIT HARDWARE: W With comply with SUCK pIOV1SIOriS Or this peImlt shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT ❑ LIST ITEMS BELOW NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REQ D D PROVIDED SPACES License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE �. FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL. APPROVAL PRESENT USE OF BUILDING Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the pefformance of theprk for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lend'er's Addre .. PERMIT FEE I certify that I have read this apptati000mdsst.d�e that the above information is correct.I agree to comply WI"thtall Coii*y I s ANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes. = I SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Permittee Date wORKERS'COMPENSATIONDECLARATION 78M444 MISCELLANEOUS APPLICATION 1 CE 874 (�1-84) I heroby,aflrffi tha; I have n onrtif`l pe ofin Irizut uc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION hmsu�or�Cartfficate of WoriCers'Compensation Insurance,or a cert�fied copy thateof(Sec.3800,Lab.C). Policy Na. CompanyFOR APPLICANT TO FILL IN ■UILDIus / ADDRX ANG LED Certified copy L hereby furnished BUILDING G LOCALITY .I� DR X1f ❑ fled-cdepartmentY�-is filed with the County building inspection LOCALITY �M L� C J?L Cp RtAR t/T CROS/ ST. NXARt■T DI TPIK r t f Y Date Applicant CRofn ST. C�—�I�JE�° 1.YonfT. CERTIFICATE OF EXEMPTION FROM WORKERS' LXGAL COMPENSATION INSURANCE DXSaRIPTION LOT NO. BLOCK IAP HI�HWwr wo. (c1Rcl.i) erwTX Yw�oR a D LocwL /may,�� NO. OF ■LDGS. (This section need not be Completed if the work involved TRACT NOW ON LOT USX zONt fPXauL CONDITION/ by the permit is for one hundred dollars ($100) or lea&) USX of e1ZX OF LOT tX 11TING BLDG. I amtffy that in the pefformance of the work for which this C) permit is issued, I ihall not employ any person in say manner ovntN so as to become subject to the Workers' Compensation Laws. MAIL 4:ZC) OCCUPANCY GROUP o IE / Date Applicant wD DR X.f L" LLT NOTICE TO APPLICANT: If, after making this Certificate of CITY Ce)LjiKIA noL '3 OCCUPANT LOAD Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILXR Uft ❑ GXOLoGY INSrXaTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION occurwnaY IN/rtarwPanic Devices N I hereby affirm that I am licensed underrp onions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bu� /AFYTY PtRY1T ❑ (LIST iTXYf ■X LOQ) NO. OF XXITI nes and Profesdons Code,and my License is In full force and effect ZZZRKINAaXIG RXQ'D rROVIDXD License Number Lia Class Contractor ♦� LIMITED TIME USE Contractor Date DAT■ DATE ❑ I am exempt from the licensing requhroments as I am a PROM. TDI licensed architect or a registered profbsaional engineer ■Izt OF F. of / IN(GNAT R•e acting In my professional capacity (Section 7051, Bur -K IIT I NG ■LD 6. STORIK. / ONATURt cti meas and Professions Code). PR Xf tNT ufX of MU-11-DING FINAL APPROVAL Lie,or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF XXISTING BUILDING/ 1 ON LOT AND u/X I hereby of Irm that I am exempt from the Contractor's W.CT.T License Law for the following reason (Section 70315, Buaf- � � . nese and Professions Code): No. PARKING I, as owner of the property, will do the woric and the /rwcXf PROVIDXD 1 Fail structure is not Intended or offered for sale (Section 7044,Budnen and Professions Code). TOTAL 93� - 00 CONSTRUCTION LENDING AGENCY PR0ro1XD Ult OF BUILDING , CWCYC 93.00 I hereby affirm that there is a construction lending agency CANGE GO for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name 1 6 J29r9l PR OP Of tD MAX. OCC. Lender's Address I tify thzt I have read this application and state that the PERMIT Ft!< { 1577 1 AI111]:Jh � above information is correct.I agree to comply with all County I6aUANC¢ Ree 130 0 ordinances and State Iaws relating to building construction, and hereby authorize IepreseIItatives of this County to enteI TOTAL FQS upon the abovo-mentioned;rorerty for inspection purpose& SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o ee Date