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Home My Public Portal About9528 GIDLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M4" 875 (2-80) CMISCELLANEOUS APPLICATION CE 876 I hereby affirm that I have a certificate of consent to {elf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Iruure, or a certificate of Workers'Compensation insurance,or a certified copy thereof(Sec. 3800,Lab..C.) Policy No. Company. FOR APPLICANT TO FILL IN BUILDING ADDRca■ Certlflod copy is hereby furnished. ■uILD INa r� LOCALITY ADDRESS Certified copy Is filed with the county building Inspection EAREsr LOCALITY department. CRO// ■T. Date Applicant EAREST Ir^ DISTRICT NO. 6 Ur TYPE "'C", ■Y CRO■S ST. CONaT. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DEsc RIrTION LOT NO. ■LOCK NAS HIGHWAY Ho. (C CL/) /TAT[ MAJOR SECOND LOCAL //��rr��1,,�� NO. OF ■1-1311/. \+"„ section need not be em leted it the work involved TRACT NOW ON LOT USE ZONE {P EC IAL CONDITION/ by the permit is for one hundred doilan ($100) or leas.) USE of SIZE OF LOT Exl/TING BLDG.O. I certify that in the performance of the work for which this permit b Issued, I shall not employ any person In any manner NCR �I� 0 so as to bacome subject to the Workers' Compensation Laws. AIL PAN GROUP F_ LU ADDRESS D .CL Date Applicant W TEL. � NOTICE TO APPLICANT: If, after making this Certificate of cITY o - N A Z Exemption, you should become subject to the Workers' APPLICATI NFO XI ARE: Compenutlon provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE EJ GEOLOGY INSPECTION El No Spec. Kno'W1. deemed revoked. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY IN`§PKCT1011 Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMrr Q (LIST ITEM{ BELOW) 9 (commencing with Section 7000) of Division 3 of the Bust- No. or carr{ f❑Y([a'[_��{ and Professions Code, and my license If In full force and PARKING. iA ct' SPACES RCG'D FR OVID ED joicense Number Lic. Clan LIMITED .TIME USE ` (ntractor Date DAT[ DAT/ I ■m exempt from the licensing requirements as I am e licensed architect or a registered professional engineer SIZE of no. of SROM I TO. INSPECTOR'■ acting In my profamional capacity (Section 7051, Bus- EXISTING •LOG. STORIE■ SIGNATURE Ineu and Professions Code). 11� RESENT USE OF BUILDING FINAL APPROVAL !_ Lic.or Ret.No. Dater CJ774 HOME OWNER-BUILDER DECLARATION No. u1LDINo■ ON LOOT AND D USKSQ - I hereby affirm that, I am exempt from the Contractor's 21 8S 5 A License Law for the following reason (Section 7031.5, Bust- neis and Professions Code): - NO. PARKING # e o 0 0 8 8 _- ■FACE■ PROVIDED I, as owner of the property, will do the work and the r structure Is not Intended or offered for We (Section ..• 0 0 0 0 0 0 j 7044, Business and Professions Code). rCsKD USE DF BUILDING O 1 O—83 CONSTRUCTION LENDING AGENCY r, I'hereby affirm that there Is ■ conatructlon lending agency o for the performance of the work for v6lch this permit is .fasuod (Sec. 3097,Civ.C.). Lender's Name _ PROPOSED MAX. OCC. LendeI's Address PERMIT FEE I certify that I have read this application and state that the Issuwnc[ PEE above Information Is correct.I.agree to comply with all County ordinances and State laws rotating to building construction, TOTAL Fa:E D �� and hereby au horlse representatives of this County to enter upon the e-mentioned pro y fo ction purposes. SEE REVERSE FOR EXPLANATO ANGUAGE -3 ature of tt Date WORKERS• COMPENSAIION DECLARATION "4' 'I MISCELLANEOUS APF"LICATION ?t}(IUC:9)PIN 1_' LU Ifhereby aMrm that I have a certificate ol" clui,.,w III kJ I' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' C'ompcnsaiion In>urun:e. or I a certified copy thereof (Sec 1800. lah. C'.) Policy Na Company FOR APPLICANT TO FILL IN BUILDING BLJIL121NG ADDR S ADDRESS H Certified copy' is hereby furnished. \ �\ S LOCAnJTY 1 Certified copy is filed with the county huildmV nm,lxction qTY z department., CROSSNEAREST CROSS IIT. Date_ Applicant SIZE OF L NO.OF BLDGS.NOW ON LOT OMTRICT NO. GROUP TYPE PROCESSED SY I C'ERTII-ICA•fE OF EXEMPTION FROM WORKLR`; TRACT BLOCK LOT NO. coNIIT. ,J C'OMPENSAI[ON INSURANCE ,",o� 'ClItCLA, STATEMA-ORSECOND LOCAL (This section need not be completed if the Rork in%0I%'Cd ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS r' by the permit Is ror one hundred dollars (sI00) or Ic%s.) (l F • I certify that in the performances ol� the work for which ThiOWNER TEL NO. I t permit Is issued, I Shull not employan) pers.on in ;Iny niann-:r so as.to become subject to the Workers' Compenwtion Laws. ADDRESS OCCUPANCY GROUP r" 1 Date— _ Applicant CIrY ZIP -- NOTICE TO APPLICANT: II•. after making this Uertil'icaie OCCUPANT LOAD of Exemption• you should become subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE: comply with such provisions or this Ni-mit shall be deemed TRAILER U1iE❑ GEOLOGY INSPECTION❑ No S Know]. ❑ revoked QQ� ❑ OCCUPANCY INSPECTION�I PanIC De0ces ' LICENSED CONTRACTORS DECLARATION r I hereby afFirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ LIST rTEMf BELOW I ,J I 9(commencing with Section 7000)of Division 3 of the Business NO.or Exrr5 e and Professions Code,and my license is in full force and :ITcct. wf�mG vF i^i rtC�+� v }i License Number LIC. ( lass PARKING• REQ'D E= PROVIDED �n V. SPACES . I Contractor Ilene LIMITED TIME USE El um exempt from the licensing requirements us I uDATE m u FROM: TO: DATE licensed architect or a registered professional err�incer actin in my professional capac7ly (Section 7(151. Ilnisnness SIZE or NO,OF W TOR'6 and I oIClSions Code). EXISTING BLDG. BrORIE9 ATTIRE Lie or Reg. No. Date PRESENT USE OF BUILDING r) (U FINAL APPROVALG5 —0- - �. HOME OWNER-131 IILDFR DIA LARAIION N 0.0 F t x la r I NG BUILD INCS � I ON LOT AND USE hereby affirm that I aln exempt front Ilio Conlractor"S I wcli"c Law for the follinving•reason (Section 70.11.1, Businebs and v1� Professions Code): NO.PARKING SPACES PROVIDED ❑ I, as owner of the pro]xrl), mll do tie %%Irk :lad the Structure is not intended or ollcred tun ]ale Ow-ciion 71N4. PROPOSED USE OF BUILDING Business and Professions Code). �J CONSTRUCTION LENDING AGENCY I hereby affirm that there is it construction lending agency for t the performance of the work for which this Ixnnnt is Issued �I (SCC 3097.Civ. (.). PROPOSED MAX.OCG Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct- I agree to comply with all County PERMrr FEE ordinances and State laws relating to building construction.and hereby authori Ze ntat sof this County to enter upon nSSl1ANCE FEE the above m on p per r inspection pur-prsu-s• tet' I TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE � I Dile