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Home My Public Portal About9550 GIDLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 715M444 CEMISCELLANEOUS APPLICATION 1 hereby efflrm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING lnnnre,or ■ certificate of Workers'Compensation Insurance,or AND SAFETY DIVISION e certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANTTO FILL IN wooR�u �. ❑ Certified copy is hereby furnished. BUILDING LOQ ALITY ADDRK■S ❑ Certified copy Is filed with the county building Inspection NEAREST department. LOCALITY / CRO■S aT. or Date Appllcant AKARKST V DISTRIC O. (IRIOBT. TYrt RO SKD BY CROSS ■T. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEG.L COMPENSATION INSURANCE D1FSCRIPTION LOT NO. ■LOCI( 1TATE M OR SECOND LOCAL } No. (CIRCLa) //�77��,,�� --J ��„�,� NO. OF BLDG*. (TbIs section need not 110 COm leted if the work htvQtved TRACT NOW. ON LOT USK IONK SPECIAL CONDITIONS O by the permit L for one hundred dollars ($100) or lees.) USK of U ■IIK OF LOT EXISTING ■LDG. r I certify that In the performance of the work for which this O permit Y issued, I shall not employ any person in any Inanne &A NL A4,-4 0 so as to become subject to the Workers' Compermflon Laws. AIL OCCUPANCY GROUP ADDREa■ S /� W Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of trY No. �� iy�Q OCCUPANT LOAD Exemption, you i_btuld become -subject to the Workers' Compensation provtsfbris of the Labor Code, you must forth- APPL CATION FOR -EXIT HARDWARE: with comply with. h provisions or this permit shall be TRAILER USE❑ GEOLOGY 114SPECTI0N E No Spec. Knowl. ❑ deemed revoked. ' LICENSED;CQNTRACTO RS DECLARATION occuPANcY I'�CT'oN Panic Devices ❑ I hereby affirm that I am liceriaed under�rovisiolzs of Chapter. SA-FKTY PERMIT Q ('LIST ITEMS ]BELOW) 9 (commencing with.Section 7000)of Divislon 3 of the Busi- ness and ProfaWorn-Code, and my License Is in full force and PwRKINa. elect. It ` PROVIDED i� � ■PACKS El Ll�"Number L1c..Clan LIMITED TIME USE Cti tractor Date DATa DATA ROYI To. Elpt I am exemm the licensing requirements as I am a ns liceed architect or a registered professional engineer SIZE OF- No. oP FINSPKCTOR'S acting in my'professional capacity (Section'7051, Bua- KXIaTING ■LD G. STQRIKS SIGNATURE inessapdProfessions Code). FINAL APPROVAL iylA�/ PRESENT USK OF BUILDING GG�F��Qp ++fit -aJ Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION No_of KXtpnNG ■ LDING■ ON LOT AND USK I hereby affirm that• I em exempt from the Contractor's z License Law for the following reason (Section 7031.5, Busi- non and Professions Code): NO. PARKING # D • e . 8 8, SPACES PRQVIDED , ❑ 1, as owner of-the property, wfll do the work and the o u o o • structure is not Intended or offered for sale (Section , 7044,Business and Professions Code). PI.SKD USK OF rU1LDING 7, 22-8 3 CONS-t_BCTION-LENDING AGENCY , ll I hereby affirm thatthere L a construction lending agency for the performance of the work for Y"ch this permit is Issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MA-X. OFC. Lender'ik Address PERMIT PEC I certify that I have read this application and state that.the above information Is correct.I agree to comply with all Co,unty ISSUANCE FEE ordinances and State Jews relating to building construction, TOTAL FEE and hereby authorize representatives of this County to,enter upon ic■bov -miltoned pro y or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE a eture Perml ee W, Date >r WORKERS'COMPENSATION DECLARATION CE 8 6(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of Wnsent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ' ogre, or.A certificate of Workers Compensation Insurance,or a,=tff3ed copy thereof(Sec.3800,Lab.C.). ILDI �J Policy No. Company FOR APPLICANT TO FI LL IN ADDR■DDItKSfa 7%�.�0 _ J 7 ■uDDCertffied copy is hereby furnished- I L DR[■S I N acmTo`/'44 A h 57 Certffied copy is filed with the county building inspection LOCALITYNKAR[sT dep&rtment Temple City cRo.{ ST. Applicant XIAR[ST DISTRICT IiQ. 6ilOUr TYr[ tf{[D BY �� APP d0 //Ir)( CON CROP{ 1T. I CERT'IF'ICA'T'E OF EXEMPTION FROM WORKERS' LKGAL COMPENSATION INSURANCE D[SCRIPTION LOT XO. ■LOCK YAF HaHWAr H� ialR CLK) STATt MAJOR {[CO ND LOCAL NO. OF ]SLOG{. ars (This section need not be completed if the work involved TRACT NOW ON LOT USK ZON[ ■PKCIAL CONDITIONS by the permit Is for one hundred dollsus ($100) or leas.) USK of I {IZ[ OF LOT [KISTING BLDG. I cattify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner o.NtR o U so La to become subject to the Workers Compensation Laws. MAIL "' �j _ OCCUPANCY GROUP c - a:::] I DR Date AppllciLnt -11 -77 OCCUPANT LOAD w NOTICE TO APPLICANT': If, after making this Certificate of crtY tIa NoL �`"�'r"1 F-Temlption, 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 sha11 be TRAILKR USK ❑ GKOLOGY INaPKCT1ON ❑ No Spec. Knowl. deemed revoked. l LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPtCTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter ■ARTY F[Rmrr ❑ (LIST rTKYS EKLOW) I 9 (commencing with Section 7000) of Division 3 of the Bud- No. OF KXrT■ nese and Professions Code,and my license is in full force and effect. PARKING lPA CKSR[q'D FROVIDKD License Number Lic. Class LIMITED TIME USE N Contractor DaLe OATI DAT{ W l V I am exempt from the licensing requirements as I am a TOI i licensed architect or a registered professional engineer S[1K OF No. or N IGNATOR K Z acting m mV professional capacity (.Section 7051, Bus' [KIlTIN6 BLDG.O. ■O. OP, fI6 NATURt S irumandProfessignsCcde). FINAL APPROVAL FR tfKNT U/JR OF BUILDING 8 Lie.or Reg.No. Date E l HOMEOWNER-BUILDER DECLARATION No. OF [XI{TINA BUILDINGS I hereby affirm that I am exON LOT AND USK empt from the Contractor's n I License Law for the following reason (Section 70315, Busi- ness ugness and Professions Code): NO. PARKING I, as owner of the property, willdo the work and the ■PACKS FROVIDKD structure is not intended or offered for sale (Section l 7044,BllsirtemI and Professions Code). CONSTRUCTION LENDING AGENCY a PROFOSKD USK OF BUILDING ' I hereby affirm that there is a construction lending agency t I for the performance of the work for which this permit is Issued(Sec. 3097,Civ.C.). Lender's Name FROPOSKD MAX. OCC. Lender's Address 'Ci 1 [ I certify that I have read thio application and state that the PKRMIT FCC 25.00 above Information is correct.. IFty Lromply with all County 15SUANCK FKK ordinances and State laws ro building construction, T aced hereby authorhe represeof this County to enter TOTAL FREE75, l I upon the above-mentioned pr inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE m 184 1 Tab C` i tore ofdlermittee bate r CD — T WORKERS'COMPENSATION DECLARATION CE 875 M ISCELLANEOUS APPLICATION /-� CE 876 (11-84) L � I hereby afffna that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IIS JIB fnsuro�4r a�tlflcate of Workers'Compensation Insurance,or a oart�f3ed copy thereof(Sea 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN �' ■uILDING ,{,c—?, FICertified copy is hereby furnished. D R[■■ Lo CA Certified copy is filed with the county building inspection J.QCALRY "AR T department. Dote Applicant N[AR[1T :LI !(Q 6 Ur TYT[ P /1[D ■Y CRO// ■T. l�j/ � BON/T. T/ CERTIF'IGATE OF EXEMPTION FROM WORIMRS' L[GALv COMPENSATION INSURANCE D[■CRIPTION LOT NO. ■LOCK Mw� HMHBAY no. (CIRCLz) /TAT[ MAJOR ■[GOND LOCAL NO. OF ■_oT U/[ Zo N[ sF[CIAL CONDITIONS (Thlm section IIOOd not be COIIIppIOted it iiia work involved TRACT NO7 ON Lo7 by the permit Is for one hundred dollars ($100) or las.) us[ of ■IZ[ OF LOT [XI/TING ■LD 6. I cartify that in the performance of the workfor which this o permit Bssu issued, I shall not employ any person in any maffier o.N[R so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP o ADDR[/■ 44 ~ Data ApplicantLL-j NOTICE TO APPLICANT: If, after makfng this Certfflcate of CRY �n meplL{ n..' OCCUPANT LOAD r„ Exemption, you should become subject to the Workers a APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth with comply with much provisions or this permit shall be TRAIL[R u■[ ❑ GKoLoGY IN■F[aTIoN ❑ No Spec. Knowl. El deemed revoked. LdCENSED CONTRACTORS DECLARATION oaauFwi+aY IN/F[CTION El Panic DBVICAS I hereby affirm that I am 1fcensedunderns of Chapter /AF[TY FSRMrr ❑ (LIST rr[Ms ■[LOB') 9 (commencing with Section 7000) of D�3 of the Buri- No. of [xR■ f non and Professions Code,and my license Is in full force and effect. _77111_y� PARKING R[Q,D FROVID[D r sFAQ[■ �II10 N� y�♦ �'m - LIMITED TIME USE Contractor Data DAT/ DAT/ F-1rROY1 Y'OI I am exempt from the Licencing requirements as I am a licensed architect or a registered profoufonal engineer ■IZ[ OF NO. IN/F[OTOR ■ acting In my professional capacity (Section 7051, Bus- [X is TING ■LDG. /TORI[/ 5IuR mess and Profeadons Code). / J FR[/[NT Us[ OF BUILDING FINAL APPROVAL Lic,or Reg.No. Date ` 1,4 HOME OWNER-BUILDER DECLARATION No. OF K3F1FT1INa Bu1LD1NG/ 7 ON LOT AND U/[ 1 ` (.-� I hereby affirm that I am exempt from the Contractor's I�\1 U 1 5/21/93 License Law for the following reason (Section 7031.5, Buai- �} 9873, 1- —PM12:47 nese and Professions Code): No. FARxING I, as owner of the property, will do the worix and the /FAC[/ FROVID[D structure is not intended or offered for male (Section 70441 Business and Professions Code). CONSTRUCTION LENDING AGENCY PROFO■[D Us[ OF ■UILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sea 3097,Civ.C_). Lender's Name FR OTO■[D MAX. OCC. Lender's Address PERMIT F[[ 00 I certify that I have read this application and state that the above information is correct I agree to comply with all County Isau ANCK Fe[ ordinances and State law4 relating to build}ng construction, and hereby autho tatives of this �ouaty to enter TOTAL Fa[ �QU• upon th mentio property for inspection purposes. ✓ ,^r 3 SEE REVERSE FOR EXPLANATORY LANGUAGE e o Date I 1i'ORI:ERS'COMPENSATION DECL.�R.aT10N 78MA" MISCELLANEOUS APPLICATION CE 87B 1 1 1-84) ^ I hereby a ser that I have a certificate of cornea[ to self COU1rv`TY Or LOS .ANGELES BUILDING AND SAFETY DIVISION irtst�rt. or a Lrortificate oC}Yorkers'Compenrltbn Irnsurunce.or a certifled copy thereof ISm 3800. Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN Certified copy is hereby furnished_ ■UIL°ING a ADOR[// JO GiDL�Y LOCALITY I F� Certified Lrpv Is filed with the counts bFu lding iWeetion LOCALITY 14[AR9/T department. Temple City CROs/ WT. Date applicant NKA R ESTC�-T • 71 STR ICT NO 6 UR TYPE Ct1■ED ■Y CROSS ST. CON I CERTIFICATE OF EXEMPTION FROM'YORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No. BLocK I�.. aNr wY •�o. ) STAT[ MAJOR ■[COND LOCAL (This section need not be completed if the work involved I-RACT NO. OF ■LD6S. ICIR CLE NOW ON LOT U7[ TON[ SPECIAL CONDITIONS by the permit is for one hundred dollars 151110) or less.) USE OF I SIZE OF LOT tXl/TING SLOG. I certify that In the ermrrrtance of :he �.cor4 for •s-hich his permit is issued. I shall not empley any ne-son '.n Liny manner OWNER SITS i'21N� _ so as to become subject to the ttorkezz C:mpensaticn Laws. MAIL l OCCUPANCY 3ROUP ADORE/■ {�� , ;Z*`(MoNb P.Ve 1 Date Applicant NOTICE TO APPLICANT: If. alter mak-Int: -!tis (-ertT1(_n1e -If X cIT• 1F1A1.L9R70rI NOL OCCUPAN- LOAC Exemption. you should become subject -o -he tkorkers 4P°L!CA'ICND�F =(ITHARC'. .'� E Compensation provisions of the Labor'"ade. you must torth- 1 with comply with zuch orocisiont or .his -^ermit shall be -PAILtR u/E atOLOGYN PECTION — ❑ deemed reeked. No r — No Soec. Kno`.vl. OCCUPANCY INSPECTION Panic Devices n LICENSED CONTRACTORS DECLARATION OCCUPANCY I hereby aiflrm that I am Gan_sed under pprovis)ons of Chapter - ) 9 [commencing With Section 0001 of Dhision 3 of the BusF SAP[TY PERMIT (LIST ITEMS ■[LOL7� NO. OF EXITS ness and P-0fessionc Code. and my licence is in full force and effect. G Rto'o = PRovIDtD oLicense Number Lic. Class LIMITED TIME USE 12 Contractor Date OwT/ ow TE W Z _ I am exempt from the lilznsirtg requirements as I am a TOI m I licensed architect or a registered pmtessional engineer ,IxE of No. of INSPt CTOR'■ Z actin¢ in :ny professlonal .-nrici.r, Se:;ion -f1`1. Bus- EXI/TIN. ■Loa. "2.rj�0 s lT ORIES I fI6NAT [ iness and Protessicns Cade). PRESENT u/E of BUILDING FINAL APPROVAL � Lic.or Rea. No. Da:e .I HOME O«'NFR-BUILDER DECLARATION NO. of txISTIHG BUILgIHa/ D rd+ I hereby affum that 1 am exempt from the Contractor's ON LOT AND U/[ I License Lau-,for the following reason (Section -931.5. Buss- ness and Prntessions Code): NO. PARKING 1, as ,owner of the property %% du the wort; and the SPACES PROVIDED structure is not intended or offered for rile (Section 7044.liusincss and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby a1Tu7n that there is a construction lending agency FVAMIGA Wp for the performance of the work for which this permit is lsRJCd fSec. 3097.C-rv. C.). Lender's Name PROPOSED MAX. OCC. Lender's.address I certify that I have read this application and state that the PERMIT FEE 25.00 above information is correct. l agree tocomply with all County IssuANct FEE - ordinances and State laws relating to building construction. and he by authorize representatives of this County to enter TOTAL FEC 25.00 I. upon h abovc-mentioned property for Inspectio p rposes r SEE REVERSE FOR ErPI 4NATORI' LANGUAGE � 00 I Signature o Permitt Date