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Home My Public Portal About9526 GIDLEY ST_Miscellaneous__ WORKERS COMPENSATION DECLARATION 76 7 CE 85(11-94) MISCELLANEOUS,APPLICATION +, CE 876 (� I hdrl ky affirm that I have r t4 of consent to self inure.jw a eerttfiate of Workare C6mpenta�lon Insurance,or COUNTY OF LOS ANGELES - BUILDING AND SAFETY DIVISION a certi{]ed copy thereof(Sec.38010,14b.Q. 3 Pommy Imo• Company FOR APPLICANT TO FILL IN IUbwcN� ❑ Ca W1W copy is hereby tithed ■UILDIN6 C LOCALITY ci �.aq.,� building y,,,,y.,.�y,.�,,,, A Q D R E■1 l CmttW copy if fled with the County building hrspbCtion A LOCALITY NERS■T fit, Temple City CROSS ■T. bate Applicantn[wwE■T ^ DI#rR Gw r TYPE CE■■ED ■Y ' ■a . «� \ V cow CT RTI) IGATE OF$XE�IION FROG[WORKERS' CwoST t•-4'� LEGAL /TAT[ MAJOR SECOND LOCAL I COMPENSATION INSURANCE OE■CRIMON_ Lor H No. ■LO Cx MAP HXGAY NO. ICm ct-z) ��,,tL, ecNOOF ■LDQa. ZONE (This Stion need not be completed If the work bnoived TRACT NOS/ON LQT ■ ■P[CUL CONDITIONS by the permit is for one hundred dollar's (SIQO) or less•) u■E or, I SIZE OF LOT EXIaTrMG BLDG. I �' that to the performance of the work for which this a permit is issued, I zha.11 not employ any person in any mummer OWNER tea, µ 4' ad u to become "ect to the Wodcros' Compensation Lam OCCUPANCY GROUP O MAILCD wDOREs1 11�0� �A- �1► R lJ\ �a� Date CANT: If, �gl��rBL OCCUPANT LOAD NOTICE TO APPLICANT: Ii, Biter� this Certificate of crrY � �u o. 'may -zC1 Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth I with comply with such provisions or this permit shO be -, O deemed rYvok6d- TRAILER USE GEOLOGY IN/P[CTION No Spec. Knowl. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY IN*PKCTIONO El Ch I hereby affirm that I artt llcensed under provisions of Chapter 9 (commencing with Section 7000) of D •ision 3 of the Busi { SAFETY P[ rr J (L T rrE1J, ■[Lo■r� M1 - NO, OF EXIT/ ncss and Prefessons Code, and my license is in full for Ce and effect. RKING 1PJ.CR[O D PR OVIO ED I L/ License Number Lic. Class p (� LIMITED TIME USE ,p COnmctor Date DAP■ DATC W RZ L._J I am exempt from the Licensing requirements as I am i P^DN: TDA �O I licensed uchit= or a registered profemonal engineer Al 1K oP No, or INa�[cTO R'/ acting in m} profes.Ronat mpacin- Secdon .'051. Bus- [XI■TINQ SLOG. /TORI(: sl TuwE mess and Professions Code). FINAL APPROVAL (i Z�IJ Lic or Rey.No. Date PRE/[NT U/E OFBUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXID U/E TING ■UILDIN65 � U Vv I hereby affirm that I dm ON LOT ANmxempt from the Contractor's D i License Law for the following rou;on (Section 7031.5, Busi- ness and Professions rode): NO. PARKING / { I, as owner of the property. Alp do the wort: and the /PACES PROVIDED structure is not intended or offered for sale (Section g 7044,Business and Professions Code). I PROPOSED U/[ OF BUILDIN¢ CONSTRUCTION LENDING AGENnT I hereby affirm that there is a construction lending agency b. V i ) for the performance of the work for which this permit is i kwed(Sec_ 3097,Civ.C.). Lender's Name PROPOSEP MAX. OCC. Lender's Address d I certify that I have read th)s applicltion and smte thal the PERMIT FEE 25-00 above informs correct-1 agree to comply with all County ISSUANCE FEE , ordhn Stu la rolattng to buil clonstruction, m, and Mere aU Of tlrif County to enterTOT^L FEE 2-5.00 upon the p party for inspection purposes SEE REVERSE FOR EXTLANATORY LANGUAGE GE -� Dau ` wOklaRs'COMPENSATIONDECLARATION 76-M4" (20) MISCELLANEOUS APPLICATION I hereby affirmthat I have certificatempen of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate ificate of Workers'Compensation Insurance,or ■certlfled copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL INADD R■UILDIN6 � � I S S Cartifled copy laheroby furnished. ILD INo LOCAL O LOCALITY I( � � LOC AL Certified copy is filed with the county•bullding inspection ADDRK// Aw NKARKfT 641 department. CA.LITY ��1_1 PL—e G(T �' CROSS ■T. DatO Applicant NKARK*T 1 1_rot DI/TR T N OUR rYR RBOC/ iD �x -CROEX ST. ko Lo E� A �- � CON■ CERTIFICATE OF EXEMPTION FROM WORKERS' LitGAL + D COMPENSATION INSURANCE DK/CRIRTIQN" '{,OT NO. ■LOCI( PAP Hlo� Y } wo. (CIA CLKI 1TATK MAJOR fKCONO LOCAL (�r�/,�� NO. OR BLDG/. a �'t'7� seCt1011 need not b0 COIDp}fet�ed if the AOIY Involved TRACT NOW ON LOT � UaK ZONA; SPK IAL CONDITIONS ^ by the permit is for one hundred dollars ($106) or less.) - U/K of C8 ■IZK OR LOT Kx1aTING BLDG. I certify that in the performance of the work for which this Cr permit is issued, I shall not employ any person in any manner WNKR. ZA At 0 to u to become subject to the Workers' Compensation Laws. IL OCCUPANCY GROUP FU— D.11- / a Date_ Applicant NOTICE TO APPLICANT: If, after making this Certificate of ry No. Q / OCCUPANT LOAD Z Exemption, you should become subject to the Worken' PPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked- TRAILKR U1K❑ GKOLOGY IN■PQCTION❑ NO Spec. Knows. ❑ occ —ncw Panic Devices ' LICENSED CONTRACTORS DECLARATION ,ANcY rNfrKc ❑ I hereby affirm that I am licensed under provisions of Chapter ■AFKTY PKRYIT ❑ 9 (commencing with Section 7000) ppf Dion 3 of the Busl- (aur ITKY■ ■¢LOB) no, of Kxlrf Division neu and Professions Code, and my Leto is in full force and effect. PARKING ■PACK■ REq'D E= PR OVID KD .Ucense Number Lic.Clan --- LIMITED TIME USE 'Contractor Data - DAT■ DATK I am exempt from the licensing requirements as i am p Fwow1 Tot• licensed architect or ■ fegistered professional engineer slxK OFNo. of IN SPKcroR's acting In my professional capacity (Section 7051, Bus- kXUITING BLDG. t ■TORIK■ ■IGNATURK Ines and Professions Code). S'fOfz i N FINAL APPROVAL ■KNT U/a: OF BUILDING / Lac.or Reg.No, Data 117 XX HOME OWNER-BUILDER DECLARATION ON of AND USa ■u1LDlNas ON LOT AND K I bprebyaffirm that, I ■m 'exempt from the Contractor's License Law for the following reason (Section 7031.5, Bust- ness and Professions Code): NO.PARKING 2 (] 9 A fPACK■.PROVIDCD 1, as owner of the prgperty, will do the work and the structure is not intended or offered for Bale (Section #'6'0 0 o 88 - 7044, 87044, Business and Professions Code). h0■KD UfK OF BUILDING 0 0 0 CONSTRUCTION LENDING AGENCY I hepaby affirm that there is a construction lending agency 0 1..04-82 for the performsnce of the work for.'w.hich this permit is issued(Sec. 3097,Civ,C.). Lender's Name PkoaosKD YAX. OCC. Lender's Address REKNIT F{ES I certify that I have reed this application and state that the above Information is correct.I agree to comply with all County IKKUA.Nce FE! ordinances and State sews roll tiv to building C construction,ytoenter TOTAL FSE and hereby authors presentetives of this County to enter �.J. 0� a e- ned property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE to Permittee Date