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Home My Public Portal About9548 3/4 GIDLEY ST_Miscellaneous__ WOR1:ERs'COI+SPENSATION DECLARATION ,_:E 8 (11-641 MISCELLANEOUS APPLICATION a I hamby affirm that I have a cmtiflcate of consent to self COUNTY OF LOS ANGELES BUILDING .4ND SAFETY DIVISION re, or a car if ate o£Workers'Compensation Insurance,or insure, u a certf led copy thereof(Sec 3800,Lab.C.). t Policy No. Company FOR APPLICANT TO FILL IN ■UILn114 f/ ADDRI/■ Certifled copy is hereby furnished. ■U1Ln1ND f LOCALITY y.,.� ADDR[/■ l ❑ Certf W copy b ffied with the connry building inspection LOCALITY Temple City NzA"ST ordepLrtmaat_ CRO1T, . Date Applicant N[ARKKT DISTRICT 0;3F TYPE P [■1[D ■Y CROS/ ST. JL0,00je 61V411f�Gj CO I CERTTFICATE OF E)EMY17ION FROM WORKERS' LEGAL COI�ENSATION INSURANCE DESCRIPTION LOT NO. 5'3 LOCK MAP RaN.AY NO. (c1RCL[I STAT[ MAJOR SECOND LOCAL NO. OF IILDG/. (Tftis secdon need not be completed if the work involved TRACT NOW ON LOT USE XON[ SPECIAL CONDITIONS by the paanh is for ossa hundxed dollars (5100) or less) I USE OF I SIZE OF LOT [%ISTING SLOG. I certify that to the performance of the work for which this permit is issued, I &hall not employ any person in any manner OWNER U sou to become subject to the Workers' Compensation Laws OCCUPANCY GROUPYAIOc L drive O ADDR[1/ Ea::] � I Data Appliaat TCL. NOTICE TO APPLICANT: If, after making this Certificate OI CITY S No. b OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compeasadon provisoes of the Labor Code, you must forth- with comply wsuch provisions or this permit shall tx deemed revoked TRAILER USX: "i a[oLoar IN/P[CTION Nc Spec. Kn att owl. - LICENSED CONTRACTORS DECL.-kRATION OCCUPANCY INSPECTION Panic Devices p [ hereby affirm that I am licensed under pprovisions of ChapterI 9 (commencing with Section 7000) of Dh-Won 3 of the Bu¢ SAFETY PERMIT (LIST ITEM ■ELOx) NO. OF EXITS gest and Professions Code,and m} license is in full force and �� PARKING eREO'D PROVIDED ffect. fPAC[f I License Number Lie. Class LIMITED TIME USE Contractor Date PATI oATI i Q I am exempt from the licensing requirements as I am i FROYI L I Licensed archi[em or a registered professional engineer SIZE OF nC. OF � IN IGNA ORAS z amain in int• professional =akin' LSecdon 7051. Bus- EXISTING SLOG. 'TOR IIS SIGNATURE L7 iness and Professions Code). PRESENT U/[ OF ■ FINAL APPROVALUILOING Lic.or Reg. No. Date = f P HO\LE OWNER-BUILDER DECL.aRATION NO. OF EXISTING ■UILOIN' S I ON LOT AND USE I hereby affirm that I am exempt from the Contractor's �p License Law for the following reason ISecdon '0315. Busi- 1� new and Professions Code): No. PARKING I 1, as owner of the property. will do the stork- and the . SPACE/ PROVIDED structure is not intended or offered for sale (Section ( 7044,Business and Professions Code). . CONSTRUCTION LENDING AGENT" g PROPOSED USE of BUILDING I herebv affirm that there is Is construcoon lending agency t f for the performance of the work for which this permit is issued(Sec.3097,Civ.C_). Lender's Name PROPOSID MAX. OCC. Lender's Address ( I ' that I rend ppLicario and suu fiat the PERMIT FEE 25,00 It I¢f is COnecL 1 t ply with all County ISSUANCE FEE or lays rola ding construction, and h this County to enter TOTAL FE[ 25.00 �• i npp lKJvo- rt inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE of Poe Date WORKERS'COMPENSATION DECLARATION 76M444 CE 876 (11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a cortfficato �n of consent to self krwCOUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION re, or a certificate of Workers'Compensation immpe,or � a certified copy thereof(Sec 3800,Lib.C.)� Policy No. Company FOR APPLICANT TO FILL IN ■UIADDRLDINs /f� [// Certified eopy'is hereby furnished. ■u1LDlwo LOCALITY XX ADbR[// 9540 GIMPY -MEET Certified copy La-flied with the county building.inspection LOCALITY N[ARKST [}G department. 3cwoa/ /T. Data Applicant N[AR[/T DIsTRIGT RQ. GwouP TVP[ P [//[D BY CROSS ■T. OTTVBLVD, �/ CON/T. )(}( CERTIFICATE OF EXEMPTION FROM WORMERS' "GAL o COMPENSATION INSURANCE D[■CRIPTION LOT No. ■LocK No. x»H.A. - wo. (clw Cis) /TAT[ MAJOR /t CO ND LOCAL NO. OF BLDG■. (Thi* section need not be completed if the word involved TRACT j9QqR NOW ON LOT 9 U/[ ZON[ sr[aIAL.CONDITION/ by the permit is for one hundred dollar (5100) or leas.) U/[ OF BIZ[ OF LOT [XI/TING ■LD I certify that bra the performance of the work for which this 07RQ 604t- C:3 permit is Imed, I slWl not employ any person In any mannekX o■N[R of building So ax to become subject to the Workers' Compensation LAWL MAIL OCCUPANCY GROUP 1C'3- Date 9—`90-9 5 Appllmnt ur NOTICE TO APPLICANT: If1 f C to of c-Y --- OCCUPANT LOAD o_ s Exemption, you should become subject to the Workerg g-5 5-5001 Compensation provisions of the Labor Code,you must forth APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit stall be deemed revoked. TRwIL[R u/[ E] G[owar IN/P[eT1oN El No Spec. Knowl. LICENSED CONTRACTORS DECLARATION ocaurwwar IN■P[cTION IM Panic Devices I hereby affirm that I am ]lensed under proviatO njof CII■p.ter /AF[TY r[RMIT (LIST rr[Ys ■[Lo■) 9 (commencing with Section 7000) of Division 3 of the bad NO. OF [XIT/ neo and Professions Code, and my Hcmw Is h, full force"LX Name of business FA iK effect. ; [■ R[p�D - PROVID[D IN 6 License Number L1c Class PAOLIMITED TIME USE Contractor Date DAT. DAP[ I am exempt from the licensing requirements as I aa licensed architect or a regiytered professional erequirementsm es¢, BIZ[ OF No. w Y Irl GN Tow•■ acting In my professional capacity (Section 7051, Bur [XI/TING BLDG. TORI[/ ■IG Nwru R[ lneu and Professions Code). PR[ DIGAMGE s[NT U/[ OF BUILNG FINAL APPROVAL Lic_or Reg.No. Date Vz� HOME OWNER-BUILDER DECLARATION No. of [XISTING BUILDING/ NC—I FI ON LOT AND U1[ — — � ,/ - I hereby affirm that 1 am exempt from the Contractor's Liana Law for the following reason (Section 70315, Buri- {� p- l 4/19/9,L, nets and Professions Code): No. PARKING 5964 1 tN 8. 4: 1, as owner of the property, will do the work and the /PAC[/ PROVm[D none teqivaed structure Ls not Intended or offered for sale (Section 7044,Buslneu and Professions Code). CONSTRUCTION LENDING AGENCY PROPOs[D USE OF BUILDING I hereby affirm that there is a gonstruction lending agencyTO MANUFACTURE WOODEN AQUARIUM STANDS.. for the performance of the work for which this permit Js Lssued(.Sec. 3097,Civ.C.). Lender's Name rrROros[D MAJt.'OCC. Lender's Address PERMIT F[[ 25 . 00 I certify that 1 have read this application and state that the above Information is correct. I agree to comply with all County ISSUANCE F[[ ordinances and State laws relating to buildconstruction, and hereby authorize representatives of thlsL&nty to enter TOTAL P[[ 25. 00 I u o thon V tio ed property for Inspection purposeL SSE REVERSE FOR EXPLANATORY LANGUAGE z 11x Cont_ 9a 1995 Ci �Ilirr it I' millrr 11❑IC