HomeMy Public PortalAbout9415 GIDLEY ST_Miscellaneous__ woRlMRs'POMPENSATION.DECLARATION
CE 875 (114) MISCELLANEOUS APPLICATION
CE 876
I hereby affirm certificate
that I have a ooCompte tI concent to ,self
or COQ Y OF LOS ANGELES BUILDING AND SAFETY DIVISION
h,fl,rn or a certiflcxte of Worjcerr Compensation Insurance,or
a cart�fied copy thereof(Sea 3800,Lab.C.).
BUILDING 1
Policy No. Company FOR APPLICANT TO FILL IN AD13RK//
Certified copy is hereby furnished. uILDIna 9 C{r d !.s LOCALITY
ADDR<■■
Certified copy is filed with the county building inap on ArbC A L IT Y � � / n K AR K■T
department. ,Q C:tf CJt�ii` %.— //o CRO/■ /T.
Date Applicant NKARKrT DISTRICT NO. �?Our rcK■■KD BY
ane■■ ■T. � on■T
CERTIFICATE OF EXEMPTION FROM WO LK 6AL 0
COMPENSATION INSURANCE DKRCRirrlon LOT No. ■LOCK Yw� HarIw AY
R0. (CIRCLK) ■TATK YA R ■KCOND LOCAL
NO. OF BLDG■.
Section need not be CCQlpfeted if the Invothed TRACT
NOW ON LOT ! U/K ZDNK ■PKCUL CONDITIONS
by �e permit is for one hundred dollus ($ 0) or lea) L u■� or
61St Or LOT 9�V KXI/TING ■LD 6.
I certify that in the ormanoe of the wo for which this
�" 0
permit is issued, I not employ any pe In any manner oYNiR � � ,7i�C
p u to become subject to the Workers Co tion Laws
MAIL OCCUPANCY GROUP _�, o
Date Applicant wD DR K,■ p �1/1 /
NOTICE TO APPLICANT: ;Llc,
thio Certificate of CI-TY TKL 3 —q13 D OCCUPANT LOAD i
Exemption, you should bto the Workerd APPLICAT EXIT HARDWARE:
Compensation provisions of Code, you mutt forth
with comply with such pr this permit shall be ❑ ❑ No Spec. Kno I.
doemedrevoked TRAILKR u■K aKOLoor In■PKCTION
LICENSED CONTRDECLARATION oaaurwnar IN■PKaTIox ❑ Panic DevlCe El
I hereby affirm that I am lider{provisions of Chapter
9 (commencing With Sectiof Dh Won 3 of the Bums- ■AFtTY rBRYR' ❑ (LIST ITtY■ B/LOi�
NO. Or KX ■
nest and Profeuions Code, cense Is In full force and
effect.
PARKINGCKSRKQ
BrACK■
License Number Clm
Contractor LIMITED TIME USE
Contractor Date DAT/ T■ (}3
I am exemptJpr �es�eonal
llcmuing requirements as I tm a � 04
Iicensed archregistered profbaslonal engineer ■rzK Or NO. OF : IN PKc
acting in my Capacity (Section 7051, Bus- Kxl/TING BLD a. ■roRls■ ■IaNATURK
inewand Profe). FINAL APPROVAL
Lia or Reg.No. Data rR6■KNT U■K OF ■UILDIN6
HOME O R-BUILDER DECLARATION No. or KXI/TING BUILDINGS
ON LOT AND U■K
I hereby affirm that I am exempt from the Contractor's
License Law fo the following reason (Section 70315, Buss-
near and Prof ns Code): no. PARKING
I, as o of the property, %U do the woric and the /PACK■ PROVIDKD
structure is not intended or offered for tale (Section
7044,B mesa and Profesidons Code). _
NSTRUCTION LENDING AGENCY rR Po■KD u■K or BUILDING
1 hereby that there Is a construction lending agency —2,0 113.
for the Pe ormance of the work for which this permit if
issued(Sea 3097,Civ.C.).
Lender's Name
rR OPO■KD MAX. OCC.
Lender's Addmss
rHRMIT ITEM �
I cmtify that I have read this application and state that the
above Information Is correct.I agree to comply with all County IasuANcs FSK
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FRK �O
upontl p-above-mentloned property for inspection purposes
./ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa of Permittee Date