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Home My Public Portal About9538 GIDLEY ST_Miscellaneous__ i 14ORI:ERS'COaIPEVSATIONDECLARAT10N 76M444 CE 87765 (1184) MISCELLANEOUS APPLICATION �t -� r � L. I hereby affirm that I have a certificate of consent to soli COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ,ILfll ins;je, or a certiflnate of Workers'Compensatbn Innlrnnce,or a=Tdfied copy thereof(Sec.3800,Lab.Q. �'J I Policy No. Company FOR APPLICANT TO FILL IN woow a �✓p 17 Certified copy is hereby furnished- LOCALITY■ulLnlNa P A AD DR[1■ U 1 ZFF C . LOCALITY ( i Certified copy is filed with the county building inspection a LocwLlrr /� tU r IS EfT department. �(! 0 t vLo A. R. Data ,Applicant NEAREST DIS CT No. aROuF TYPE CE11ED ■Y CROSS ■T. Dp CON i CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ` COMPENSATION INSUR,A_NCE DESCRIPTION LOT NO. ■LOCK MAP Nw.WwY no. (clRcl.SJ STATE MAJOR SECOND LOCAL NO. OF ■LDGS. (This section need not be Completed if the work invoived TRACT .131. 0. LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or Im) uam OF 411 I certify that in the performance of the wort for which this ■IZ[ or Lor EXISTING ]BLD a. permit is Issued, I shall nor employ any person in any manner X OWNER M a-- so as to become subject to the [Yorkers' Compensation Laws. a MAIL a ('�, � �J OCCUPANCY GROUP _— 1 Dato applicant AD DR[S1 7 d /J�� — NOTICE TO APPLICANT: If, after making this Certificate of Z crrY (� �� NoTIE�f Z � OCCUPANT LOAD - E.-emption, 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 shall be ° TRAILER USE I] a[oLoar INSPECTION i No Spec. Knowl. deemed revoked N LICENSED CONTRACTORS DECLARATION occuPANc r INSPECTION LXPanic Devices M I hereby affirm that 1 am licensed under provissons of Chapter 1 9 (commencing with Section 7000) of Division 3 of the Buri SAFETY rERMrr ILlsr STEMS ■ELowi NO. or EXITS ness and Professions Code, and my license-is in full force and effect. PARKING R[O'D D PROVIDED 9PAC[S License Number Lic_ Clio LIMITED TIME USE �i Contractor Date OArf DArf x El I am exempt from -he licensing equirements is I am 1 -D I licensed architect or a reeistered professional angineer 51Z[ or no. or IN■PN CTO R 1 z - acting In mt pro(g9opal A=a6ty LSection_ 051._Bus- - FX12TING �Lno- - - -- STORIES -- - - - - --- - -- ■IawruRE -- inesa anaTrofessions Code). PR K[NT uS[ or 1UILDINa FINAL A PROVALE �17 � _ Lic.or Reg. No. Date i T_ 1 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING ]BUILDINGS 1 1r, ON LOT AND Uf[ I hereby affirm that [ am Tempt From the Contractor's A�/tII,V/1r�1•t_`rr/ 1 License Law for the following reason [Section 031-5. Busi- ness and Professions Code): NO. PARKING ❑ 1, as owner of the Oropertv, \viii do the %vork and the SPACE! PROVIDED structure is not intended 'or offered for ale Section i 7044.Business and Professions Code). CONSTRUCTION LENDING .AGENCY X PROPOSED USK Or ■UILDINa I hereby affirm that there Is a construction lending agenLy W (cs' �C-I[A for the performance of the work for which this permit is 1 issued(Sec. 3097,Civ.C.). Lender's Name PROPOIED MAX. OCC. Lender's Address 1 25. I certify that 1 have read this application and state that the PERMIT F[[ above information Is correct-I agree to comply with all County ISSUANCE FEE ordinances and State lairs relating to building construction, aced hereby atlthortze representatives of this County to enter TOTAL F[[ 2-$.00 above n ned property for hupectio pure s SEE REVERSE FOR EXPLANATORY LANGUAGE a WORKERS'COMPENSATION DECLARATION CE 875 (1 T�4) MISCELLANEOUS APPLICATION {� CE 878 LI I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Seo.3800,Lab.C.). Policy No. CompaADDR ny FOR APPLICANT TO FILL IN ■U KSS (, [// F1Certified copy is hereby fu fished. ■uILDINo 4 LOCALITY ADDRKS/ F Certified Copy Is flied with the county building tnepection /,L..AL-Y / 1 J N[wRReT department. �� G C�/ / CRO// /T. Date AppllCaatNAR[aT 6 w, �� /��,/ OI/T7[f�T Np 6R TYt -ROC [D ■Y CR[O// 6T. (/�j5[{6 Qf F 7 CERTIFICATE OF EXEMPTION FROM WORKERS' LKawL G/ COMPENSATION INSURANCE DK/CRIP710N MAJOR /[C N LOT NO. ■LOCK Yw� (CIRC K) MD. IIRL /TAT[ D LOCAL /�,�� No, of ■LDGS. (This wtioTl need not be "Im hated if the Rork tnvolved TRACT NOi ON LOT USK ZON[ ■P[CIAL CONDITION/ by the permit is for one hundred dollars ($100) or less.) USKerOF /IZK OF LOT Kxl/TING SILOS. I certify that to the performance of the worst for which this � permit Is Issued, I shall not employ any person In any manner O.N[ROF so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP rr Date A Iicant uAIL ADDR6// PP NOTICE TO APPLICANT: If, after making this Certificate of CrrY ,¢,e(�,.lQ/ no'. 1 OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be ❑ ❑ No Spec. Know]. deemed rovoked. T7[AIL[R U/K 6[O Lo 6Y In/PKcrloN ElWCENSEDi ONTRACTORS DECLARATION occU�wncr IN/�[aTloN 34 Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Buss /AFKrY P[Ru ❑ (LIST rtKM/ ■[Lo.) No. of [xIT/ ness and Profesaions Code,and my license is in full force and effect PARKIN G R[q'D PROVID[D 1PAC[■ (L�llceanw•NI umber Liic. Clan LIMITED TIME USE Con me or )ate DAT■ DAT/ P.O.: TDI F1 am exempt from the licensing requirements as I am a licensed architect or a registered profbuional engineer SIZ[ Or No. of IN■P cro R'/ acting In my professional capacity (Section 7051, Bur Kx u71N6 ■LD 6. /TORI[■ ■16 ATURK fnew and Professions Code). PRK■KNT UDR OF BUILDING SC FINAL APPROVAL Lia or Reg.No. Date �09 HOME OWNER-BUILDER DECLARATION No. of [xl/rina BUILDING/ 5�8A ON LOT AND USK I hereby affirm that I am exempt from the Contractor's # ..D .I. 88 License Law for the following reason (Section 7031 S, Busi nen and Professions Code): NO. PARKING O O O O,O O I, as owner of the property, will do the work and the /PACKS PROVIDKD 'I Q20'-88 structure Is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPO■KO USK OF BUILDING S 'C'E'41 I hereby aifIrm that thdre to a construction lending agency 7!f for the performance of the work for which this permit is tuned(Sea 3097,Civ.C.). Lender's Name PROPO■[D MAX. OCC. Lender's Address d PIRMIT FSR 1 COtti{y that f have read this application and slate that the above Information is correct I agree to compply with all County InaUANC¢ Rest C ordinances and State laws relating to buIlding construction, O rld hereby authorize representatives of this County�Q enter TOTAL.FK¢ on the aborerm tinned property for inapaciion/(tyCpea ,f r � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee U Date