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Home My Public Portal About9522 GIDLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76MA-44 Z9 MISCELLANEOUS A P PL IC A T I O N CE 076(1 �I I hez/by affirm that I have a insure of consent to self > �( OF LOS ANGELES BUILD NG*,AND SAFETY DIVISION tnanor a certificate of Workers'Compensation Insurance,or a ceill;d copy theroofLQ&m 3800,Lab.C.). 0 Policy Noll-C%VZ S mpany Sr tIV x-19APPLICANT TO FILL IN ■uILDING +> ADDRE■/ p� CcrttI ed copy is hereby furniihe& ■Jk U I LD I N DDR[■ 5—Z't 111 fs`f r LocwLmY Certified copy Is ffled with the county building inspection LOCALITY N[ARKST department. 4-Y Ch (7 stf> C O// /T. Date Applicant NEAREST ( /� D, R nq� aR u► TYPE ■/[D ■Y CROSS ■r. 1..A`+�rRL�!!�"}�4 TZ""9 �CCi- RLQ i CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LE GAL COMPENSATION INSURANCE D[■CRIPTION LOT NO. ■LOCK LLA► HpH�wY ND (CUCu) STATE YAJOR /[GOND LOCAL //�77�'�I,,�� NO. OP ]SLOGS. Crbis section need not be C07r1pl0 ted if the Work invotved TRACT NOi ON LOT UOK ZONE /PE CIAL CONDITION/ CD by the peffiit is for one hundred doilars (=100) or leer,.) USK OF I certifythat in the performance of the work for which this ■IZ[ OF LOT EXISTING ]SLDG. permit is issued,i shall not employ any person in any mannRr O.N[R so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPEZ�l o Date Applicant ADD.[■/ qj 2Z Gt� 1-_s rEL. OCCUPANT LOAD LU NOTICE TO APPLICANT: If, after making this Certificate of CITY C,c. NO. /j 5C7-�5� On Exemptio you should become subject to the Worliers' z Compensation pr.,,W ns of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be deemed revoked. TRAILER u■E ❑. GEOLOGY 1-9-IONElNo Spec. Know]. LICENSED CONTRACTORS DECLARATION OCCUPwNaY IN/r[arroN Penlc DBVICes I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bull- SAFETY PERMIT E] (LIST rT[Y■ ]SELOy) NO. OF EXITS ness and Profeesions Code, and my license is in M force and d� S S—, PARKING lOCt• R[q se 'D PROVIDED LicenNumber G( ��'13 Lie. Class C- `�f( C ^ T I�'CLGO'�I?1 �sl V( 5 /�A C[/ Contractor /�A-(� �,��•+ w LIMITED TIME USE Contractor "'i•~I + L�6 Date-3 Z Z-`S DAT/ DAT, I am exempt from the IlDenngrequirements as I am a ►"D�� TD. licensed architect or a registered profbsdonal engtrbew /rzE OF No. OF IN 1 TOR K acting In my professional capacity (Section 7051, Bur ExI■rlNo ]SLOG. rrowlE■ ( sr TUR[ inerland Professions Code). �1J�JTa+�G��. I'�� FINAL APPROVAL G��J Lio,or Reg.No. Data E■[NT u/[ of 0 ILD IN J`T HOME OWNER-BUILDER DECLARATION No. of EJcurrxG BUILDINGS ` a � NO F- ON Lor wwn u/[ I hereby affirm that I am exempt from the Contractor's 1 r License Law for the following mason (Section 70315, Busi- 1.-) DODD-ODOI 6/ 3193 nes/ and Professions Code): NO. PARKING I V .. .__ • El _ I, as owner of the property, wM do the work and the SPACES PROVIDED -- - _ -L' structure Is not intended or offered for sale {Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY oPo/[D u/[ of ■ulLnrnG �J�r'Ps '-T I hereby afffim that there is a construction lending agency for the, performance of the work for which this permit Is Issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address �l PERMIT F66 w I amtify that I have read this application and state that the above information is correct I agree to comply with all County 19SUANCIK FEE ordtmnces and State laws relating to building construction, and hereby authorize r roeontatives of this County to enter TOTAL FEE (� upon the above-menti property for inspection purposes 3 rit,r y�,� SEE REVERSE FOR EXPLANATORY LANGUAGE Signa of Permittee Data WORKERS'CONiPENSATION DECLARATION 76M4" r i CE 876(11-84) M ISCELLANEOUS APPLICATION I hereby affirm that thave a ate at consent Insurance, to sett COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION htsnro or a certiflL�te of WorWoixers'Compensatsurance,or a cert�fied copy thereof(Sec-3800,Lab.C.). Policy No. Company .FOR APPLICANT TO FILL IN ADDRU55 ❑ Certified copy is hereby Furnished- ■uILDING -•r C1t-k9L LOCALITY Z DR[s■ p1Fj11 e'1ii�1.� 3Z- L` C1T I i ❑ Certified copy is fled with the county banding inspectio Z CALITY c*o.i rr. department. Date Applicant: n[wREEr DIaTRIcJowoy� TYF[ [aS[D BY CRaS■ ■T. CONST ` CERTIFICATE OF EXEMPTION FROM WORFLERS' LEGAL f� COMPENSATION INSLRA_NCE DESCRIPTION LOT NO. 1LO CK ..Ar -WAY no. (clw CL=) STATE MAJOR SECOND LOCAL n, NO. OF ■LDGS. (This section need not be completed if the work involved , TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less-) u■[ OF ■IZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this _ Permit is Issued, I shall not employ any person in any manner OWNER K 0 88�7 L J4w10 t�h L so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP = MAIL � ADDRESS P•10. Date -applicant _ SEL. NOTICE TO .-�PPLIC.aNT: If, after tmkirtg this CtrtiIIcate of clrr p�YLC+{� p l� NoOCCUPANT LOAD. �.G 1lp � .4,.4-b•� — Exemption, you should become subject to the Workers' — Compensatlon provisions'of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: } with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION dezmed revoked ❑ No Spec. Knowl. N LICENSED CONTF-ACTORS DECLA RATION OCCUPANCY INSPECTION Panic Devices ❑ I I hereby affirm that I am licensed under pp ovisionS of Chapter ■AF[TY PERMIT E] LIST ITEMS ■[LOW) 9 (.commending with Section 7000) of Dtvision 3 of the Bush 4 NO. of EXITS ness and Professions Code, and my license Is in full force and PAR effect. KING PROVIDED SPACES License Number Lic. Class LIMITED TIME USE !3 Contractor Date DATR OATH w r+oMl To F] 1 am exempt from the 1Icen env requirements :u I am a D ) licensed architect or a registered professional engineer SIZE of No. of INarEcroR's Z acting in m% profe�oaai capaciry: (Section 051. Bus EXISTING SILOO. STORIES ■IGNATURE inessand ProfessiomCode). FIN PPROVAL PRESENT Us[ OF BUILDING v Lic.or Reg. No. Date i HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS O ON LOT ANO USE YI/ I herebv affirm that I am exempt From the Contractor's 1' License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING I, as owner of the property. will do the %vori: and the 'PAC[' PRoviDED structure is not intended or offered for sale (Section 704-4,Business and Professions Code). CONSTRUCTION LENDING AGENCY' a PROPOSED Uf[ OF BUILDING I hereby affirm that there is a construction lending agency i for the performance of the work for which this permit is 1-N1k issued(Sec. 3097,Civ.C.). Lender's Name \ PROPOSED MAX. OCC. Lender's Address i I certify that l have read.this application and state that the PERMIT PSC above information is correct-1 agree to comply with all County ISSUANCE FEE m ordinances and State laws rotating to bu ding construction, 'C 00 and hereby Authorize representatives of this County to enter TOTAL FEE LJ.W F upon the above-mentioned property for inspection purposes. % SEE REtiERSE FOR EXPLANATORY LANGUAGE Signature of P-rnittee Da e { )VORJCERS'COMPENSATION DECLARATION 76M444 CE 876 (2-80) MISCELLANEOUS APPLICATION I hereby af7ert that I have ■ certificate of gonsent tQ salt COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION fhsuro, or a certificate of Worker'Compensation Uuurence,or a certifted copy thereof(Sec.3800, lab.C.) Policy No.— Company FOR APPLICANT TO FILL IN ■u1LDIG {'2 MU""'- �I ❑ Certified copy is hereby fulnLhed. ■UORKSG �� ADDRK!/ ' �C / LOCALITY F-1 Certified copy is filed with the county building inspection NKA[ y department. OCI�LITY T�m P IL,� C/ � C CRO ■T. Data Applicant ARK►T ( I l �l, I, j� DISTRICT . 64 I TYr R ■[D ■Y ROS■ ST.7 ----- H CERTIFICATE OF EXEMPTION FROM WORKERS' L[GAL lV] COMPENSATION INSURANCE DESCRIPTION LOT No. ■Lock ..wP NIORrAy NO. 20'� (c IRCLK) STAT[ MAJOR /[CONOCAL (This NO. OF ■LDGS. (Taus Section need not be CUIIIpleted if the "rk invoiced TRACT NOWCON LOT USK ZON[ SPKCIAL CONDITIONS by the permit is for one hundred dollar (S 100) or le%L) USK of I certifythat to the /I oP Lor KxaTING BLDG. performance of the work for which this 0 permit is issued, I shell not employ any person In any manner 11 ow KR 1 U to as to become subject to the Worker' Compensation Laws. OCCUPANCY GROUP LU Date Ap,pllcantZ TEL. NOTICE TO APPLICANT: If, after making this Cedificate of cITY�/Q �ad No. OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, ypu must'forth- - with comply with such provisions or this permit IhO be TRAILER USK _ GKdLOGY INeP[cT1oN MS KfIOWi. ❑ deemed revoked. O �• LICENSED CONTRACTORS DECLARATION occUPANcY rN:KrKc:-nomJW Ppnic Devices ❑ I hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the BusI SAFETY PERMIT (LIST IT[FH ■[Lor) NO. OF v(IT■ neva and Profession Code, and my license Is In full force and atfect. PARKING. ■PACK■ RKq'D 4— —1 PR OVID[D License Number Lic.Class LIMITED TIME USE Contractor Date DAT■ DAT[ ❑ I em exempt from'the licensing requirements as I am ■ Pwbr TO. licensed architect or a registered professional engineer SIZE o No. of INSPKCTOR's acting Ln my professional capacity (Section 7051, Bus- [ _ G ■LbG. ■roRIK■ 91 NATUFJK mels and Professions Code). FINAL APPROVAL PRUSKNT USK OF BUILDING ✓ Llc.or Reg.No. Date 1AA_ClAA-1T HOME OWNER-BUILDERAND DECLARATION No.OF TING BUILDING■ ON LOT AND USK I hereby affirm that I am exempt from the Contractor's '+ License I aw for the following reason (Section 7031.5, Bush 12 7.7 A nwa and Professions Code): NO. PARKING ■PACK■ PROVIDED El I, at owner of the property, will do the work and the # • e • • 88 structure is not Intended or offered for sale (Section 7044, Business and.Pxofmalons Cdde). OPO/KD USK OF BUILDING a i • • o • o CONSTRUCTION LENDING AGENCY -1 228-84 I hereby affirm that there is a construction lendLag agency ��S/CAJ �Aw>A e69_(44, �' for the performance .of the work for which this permit 1s /S, ., I�–G 7- �v�LUp✓t�N7- Issued(Sec. 3097,Clv.C.). Lender's Name, PROPO■¢D MAX. OCC. Lander's Address PERMIT Fee I cgrtify that I have read this application and state that the IaeuwncE Pea above information it correct.I agree to comply with all County ordinances and State laws relating to bullding construction, TOTAL FEE and hereb authorise representatives of this County to enter upon vo-me iO, ed r party for inspect purposes. E REVERSE FOR EXPLANATORY LANGUAGE `oaY �-z7 Signature of Permittee Date