HomeMy Public PortalAbout9548 1/2 GIDLEY ST_Miscellaneous__ VVOR iiS'COMPENSATiONDECLARATION 78M444
CE 876 (11-84) . MISCELLANEOUS APPLICATION
I hm"by affirm that I have a certificate of concent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DM$ION
haaure or a certificate of Wodcere Compensation Insurance,or
a cert�fied copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILD IXa
AD DR[fl
Certified copy is hereby famished BUILDING qr G/ l t �'
ADD [f■ LA CA LITY
Certified copy is filed with the county bUlldlIIg inap.ction NSAR[fT
department-
LOCALITY CROSS fT
wJ� { C/
Date Applicant [ACROR[—S T. 7p DISTRICT nO. a P U �TYFK RO [sf[D ■Y
11 ff G-/t�f �'L i'/ Q CON WT.
CERTIFICATE OF EXEMPTION FROM WORKERS' L.[GALV` a _10�_
COMPENSATION INSURANCE D[f aR1rTIon LOT No. ■Coax w. �( YIO M.AY
wo.� -(T" IcwD�) ■tA7[ MAJOR ■[GOND LOCAL
(This section need not be CO'mppieted if the work involved TRACY NOW ON LOT Uf[ ION[ fF[QUL CONDITIONS
by the permit is for one hundred doll. ($100) or lea&) Uf[ OR
I amtfPy that in the performance of the work for which this fa[ of Lar [xlfnNa BLDG.
permit is isaaed,I snarl not employ any pence in any rhanne¢ OWN[R �f y�lf/ ,fj
so as to become subject to the Workers' Compensation LaWs AIL /) ��/ OCCUPANCY GROUP. °C
Date-A liCant -2224' B/�N %L'��C��� j
T[L.
NOTICE TO APPLICANT: If, after makfag this Certfficate of artY�,��a�t NO. X9'S G 3s'Y OCCUPANT LOAD
Exemption, you ould become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions OI this permit shall.be
be TRAIL[R USX E] a[OL.06Y INsr[CTION E] No.Sp BC. Knowl.
deemed revoked. .
LICENSED CONTRACTORS DECLARATION occu�wXCY INfF[C7ION Panic Devices E
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Dfvidon 3 of the Basi fAF[TY r[RYR (LIfY R[Yf ■[LOi�
NO. OF [7[IT5
now and Profeadons Code,and my license is in fall force and
effect- PARKINGR[q'D rR OVID[D
frACCS[■
LLiomm Number Liia Class LIMITED TIME USE
Contractor Date DAT■ DAT=
rwDNl TD.
1 am exempt from the Licensing requirements as I am a
licensed architect OI a registere.}d�.'profbaaional engineer BIZ[ of Xo. of I VGPCA oR X
acting in my professional capacity (.Section 7051, Bus- [ TINS fLD G. IT ORI[f 6 aXgTUR[
lam and ProfeesionsCode). FINAL APPROVAL �
FR[f[NT USK OR BUILDING
Lia or Reg.No. Data
HOME OWNER-BUILDER DECLARATION NO. OF [xISTIXG BUILDINGS
ON LOT AND Uf[
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 70315, Buse
nm and Professions Code): NO. PARKING
El1, as owner of the pro , will do the work and the fPwc[f PRovin[D
structure is ript-tritendod or offered for sale (Section
7044,Business and Professions Code). ;E 5 6 3 6 A
PR OFOf[D .-OF BUILDING
CONSTRUCTION LENDING AGENCY # • o e • 8 8
I hereby affirm that there is a construction lending agency /�`dG s (`I /`� o • • • • • •
for the performance of the work for which this permit is �J
Issued(Sea 3097,Civ.C.).
Lender's Name \� I Q.1 4 8 6
rR Or Of[6 YAJ[. OCC.
Lender's Addreu
FHRMIT F[[
I certify that I have read this application and state that the
above Information is correct I agree to comply with all County ISSUANCE FEIS
ordhaances and State laws relating to buil construction,
and hereby authorize reprmntatives of this unty to enter TOTAL F[E
up the abovo-mentfoned prop. y r on purposes
I SEE REVERSE FOR EXPLANATORY LANGUAGE
tare of Permittee Date