HomeMy Public PortalAbout9536 GIDLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 70 e (2-80) MISCELLANEOUS APPLICATION
I hereby arm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFER DIVISION
inru�a, of ■ certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADOR[SS
Certified copy is hereby furnished. uILDINo LOCALITY
� ADDR[.. 9536 Gidle Street
❑ Certified copy Is filed with the county building Inspection N[AR[ST
department. LOCALITY / CROSS ■T.
Date Applicant [wRKST DISTRICT NO. GROUP ITYPIK_ F OCKS9[D ■Y
JCROS■ ST.TeIR le Cit Blvd CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LROAL
COMPENSATION INSURANCE
D[■CRIFTION I LOT NO. ISL.. MAI CIG WAY STAT[ MAJOR •[GOND LOCAL
NBA
d
O. OF
LDGa. ( I
(This tDctlon need not, be completed if the work Involred TRACT NOW ON LOT US[ ZON[ ■F[C IAL CONDITIONS O
by the permit is for one hundred dollar ($100) or len.) u,[ of
IZ[ OF LOT • 11C XIS
BLDG.
I certify that In the performance of the work for which this Q
permit is hnued, I shell not employ any parson in any manner WN[R
S
DDR
o n to become subject to the Worker' Compensation Laws. MAIL a 1 �-r _ y OCCUPANCY GROUP �� W
AS
Date Applicant Z
NOTICE TO APPLICANT: If, after making thla o.Certificate of cITY\1A! � —Q 4 OCCUPANT LOAD T
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Coda, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAIL[R Us[ a[o LOGY INSP[CTION
deemed revoked. ❑ ❑ No Spec. Knows.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSFLC'RON❑ Panic Devices ❑
I hereby affirm that I am llcerued under provisions of Chapter SAFKTY F[RMIT L l (Llsr rr[MS ■[LDW) No. or ¢xlrs
❑
9 (commencing with Section 7000) of Division 3 of the Bust-
nen and Professions Code, and my license Is in full force and
effect. IFARKNa. Ir �I
SFAs PARKIN
R[q'D L�1 FROVID[D L
Llcense Number Lic.Clans CASA PRIETO S ORTIN-G GOODS ' LIMITED TIME USE
Contractor Date DAYS DATS
❑ I em exempt from the licensing requirements as I am •
r worl roI
licensed architect or ■ registered professional engineer BIZ[ OF NO. OF IM(T[CTO R'■
acting In my professional capacity (Section 7051, Bus EXISTING BLDG G. l0 , 550 I So' OF l ■laNwruR[
lnen and Professions Code). FINAL APPROVAL
� Lic.or Rog.No. Data FR[S[NT US[ OF BUILDING FEE
c
I NO.OF [xIsTING BUILDINGS NO
HOME OWNER-BUILDER DECLARATION ON LOT AND US[ One l
•/rill
I hereby affirm for that, I am exe to f(Se the Contractor's _ "]� I I_�31 9 11191
License Law for the followingreason (Section 7031.5, Bull- NG. Pw RKINa
near and Profasdons Code): ■PAC[■ FROVID[D Six ( 6 ) variance
El1, as owner of the property, will do the work and the - Lk 1 F ��10
structure is not Intended or offered for sale (S-action applied for
7044, Business and Profaadogs Code). FROFos[D ust of ■u11.DINa
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is ■ construction landing agency
for the performance of the work for winch thls permit is
Inued (Sec. 3097,Civ.C.).
Lender's Name_ PROFOa[D MAA. OCC.
Lender's Address PERMIT PQE U
I certify that I have read this application and state that the
above information is correct. I■gr t mply with all County Ls6UANCQ FRE
ordinances and State ws rola t ullding construction, TOTAL F[[
and hereby rls preae f t County to enter
upon the bovn Ion d or f napection SEE REVERSE FOR EXPLANATORY LANGUAGE
Signalure of Permltt to