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Home My Public Portal About9604 GIDLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875( 11-84) M ISCE LANEOUS APPLICATION I hereby affirm that 1 have a certificate of consent to self Insure, or a certificate of Workers'Compensation Iruunnce,or COUNTY OF LOS ANGkLES— BUILDING AND SAFETY DIVISION �J ■certified copy thereof(Sea 3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BDUIDR[//LDING A 140 64. Certified copy is hereby furnished. ■uILDINa LOCALITY �r XXwoow[S■ 9603 Certified copy Is Ned with the county building inspection LOCALrrr X[ww[■T department. Xx T alio// ST. I Dale Applicant N[AR[/T DI■T T NO. aR UP TrPc c[s/[D ■r CRO// /T. /7 / / CON■T CERTIFICATE OF EXEMPTION FROM WORKERS' L[aAL ��////// CC// COMPENSATION INSURANCE D[/Cw1Pr1oN LOT NO. BLOCK MAI HMHw Ar ND.NOOF ■Loa/. (cmcL ) /TAT[ MAJOR /[GOND LOCAL . (I"his section need not be completed If the work invotted TRACT NOB ON LOT U/[ ZON[ ■P[CIAL CONDITION0 by the permit Is for one hundred dollars ($100) or less.) ua[ OF �/ BIZ[ OF LOT [XI/TINA ■Loa. 1 certify that in the performance of the work for which thh permit Is issued, I shall not employ any person In any ince orN[R 4. � nix of building MENA ET a� as In bernme subject to the a ' Com H Laws MAIL OCCUPANCY GROUP ® cL--i ADDR[s/ Date 2 .1 11 anti L�, NOTICE TO APPLICANT: 1 er making this Certificate of Crrr No� OCCUPANT LOAD Exemption, you should me subject to the Workers — Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAIL[R U/[ ❑ G[oLooy 1X.PccTtoN ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSr[CTION E] I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Dtvidon 3 of the Bus! ■wFerr r[wMtT [:] (LIST rT[M■ ■[Low) F ness and Professions Code, and my license is In furl force an No. oP [><rT/ effect. Name of business sr CKS w[o'D rrxovlD[D ■rwcc/ LiLense Number Lie. Class LIMITED TIME USE Contractor Date DAT/ DAT. El 1 am exempt from the licensing requirements as I am a r110Y1 TOi licensed architect or a registered profeadonai enghumx /IZ[ of NO. OF IN/r[CTOR,S acting in my professional capacity (Section 7051, Bus- KXI/TING BLDG. ■TORI[/ slanwruRe Iness and Professions Code). ILFINAL APPROVAL PR[■[NT U/[ OF SUMMING Lia or Rett.No. Date ::I—:) i� dd HOME OWNFR-BUILDER DECLARATION NO. OF [x1/TING BUILDINGS Z D^�•` ON LOT AND USK l / 1 hereby aMrm that I am exempt from the Contractor's N1_I FE'S License Law for the following reason (Section 7031.5, Bud- nese and Professions Code): NO. PARKING ElI, as owner of the properly, will do the work and the /PACs/ PROVIDCD structure is not Intended or offered for sale (Section ��1 1'. . 7044,Business and Professions Code). 9971 1 �1�r('4 CONSTRUCTION LENDING AGENCY rwOPOSK0 USK OF BUILDING 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 rROPO[[D MAX. OCC. Lender's Address P[RMIT F[[ 99-00 I certify that I have read (Iris application and state that the above Information Is correct. l agree to compply with all County IsauANce Fee ordinances and State laws relating. to bulldit construction, and hereby authorize representatives of this County to enter TOTAL Fee 25 .00 upon the abov t ed property for thspection purpoaea � SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX i 11OR1:ER5't:0)IPENSATION DECL.IR.\rIU;: 76A1444 MISCELLANEOUS APPLICATION insure. CE 875 t 1 1 841 J l l hereby affl that I have a certificate of consent to self COUNTY OF LOS ANGELES. BUILDING AND SAFETY DIVISION L,IIUI�insure. o or a Lrrtifleate of Workers'Compensation Insurance.or ;l i certitled copy thereof(Sec. 3800, Lab.C.). Policy No._Company FOR APPLICANT TO FILL IN BDo 4 19 Certified ;opy is hereby furnished. g ■uILDINa wDDw[f LOCALITY 1 F-] Certffkd copy is tiled with the county building inspection a LOCALITY NEAREST department. � $� CR off ST. Date .applicant NEAREST ❑I1TwIC NO GRq�J� TYPE [31[D ■T CROSS 7T. / CONf7. I CERTIFIC.aTE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSUR.kNCE OE SCRIPT to LOT NO. BLOCK NO' (CIRC") STATE }MAJOR SECOND LOCAL NO. OF BLD6f. (This section need not he completed If the work Involved TRACT NOW ON LOT Uf[ :OHC SFf CIAL CONDITIONS by the permit is for one hundrnl ,lollurs ISM) or Icss.) use of I .ertify tint in 'he Orr ormance of -.he •pori, .'or -hick phis sI E of Lo EXI N eLOG. permit is issued. I shall not employ any person :n any manner X OWNER so as to become wkaject 7o the 'porkers' Compensation Laws „AIL OCC PnNCY GROUP a wD Dw[fs O _ Date _._ 1onliLant a E�::] TEL. NOTICE TO APPLIC INT: If. Direr makirlc :his ::=rtuiu[e I)f clr- No. OCCUPaNT LOAD Exemption, you ;Mould become subject to the Workers Compensaoon procinons of the Labor Code. you must forth- APPLICATION FOR EXIT HARCINARE - I With oomph• 'Lith 'r..h prnlisions r ;Les -emm eIiall he -RAILIR `JSE — a[OLaGY ,NSF[--IoN - -' dremed reaoked. — � — �to Spec. KnoLvl. LICENSED I.'ONTR.aCFORS DELL.\R.1TIO': OCC'JFANCY INSFUCTION Z Panic Devices I hereby at_1rm tfnr I am licensed under pprovisions of(�iaprcr r1 ( 9 icommencirta with Section 7000) of Dh-ision 3 of the BuS}- ■AF[TY PERMIT J (LIST ITEMS ■E EOMI NO. OF EXITS ness and Professions Code. and my license is in full :orce and effect. Sa R[O D PACKS FROVID ED 2 License Number Lic. Class LIMITED TIME USE Contractor Date OATS OA r■ Q I im e,cutpt :rom -he Iictmsi4 rquireme-its cs I ala i a 1 licensed architect or a remstered nrofesmonal _n_-int_: 1,x[ OF No. OF IrasFECTOR'S acting in :n%- profe,slonal -avacll,. BUS- 1XIS-7ING BL7a. JTaRIEe YW?NATURE inessand PtofeniensCode I. FINAL APPROVAL '_2 Lic ,)r Ree. N, . •+[s[ IT ')SIC OF IUILDINO —_ —. F}ale 2 ) HOME 011'-N'ER-BUILDER DECLARAFIO`; NO. OF EXISTING BUILDINGS 11 �q�pg ON LOT AND 'J■E 1 herebv at[um that I am rtempt rnm the Contractor'; LiLnnse Lau fLu :he 'i-Ilowinn season -Sec:lon _Q'I,:. Bu•,i- neSS and Proiesswits Coder NO. PARKING 1, as auner of :he property. -•ill do ;he yon, Ind :he JFACEs •,ovIDED structure is not untended or offea:d :I)r -ale -Sec-,ion I -oda.Business and Proitssions Code1. F,OFOSEO USK OF BUILDING c:ONSFRI CTlON LENDING .1l;ENt-1 1 hereby'aif-Lim that there is a construction lending agency for the performancr of the wort- for which this permit is Issued(Sec 3097.Civ.C.I. U MCA U. 'p r Lendet's Name T_ VA PROPOSED MAX. OCC. , Lender's.kddr"s 25.00 1 1 certify that l have read this application and state ,hat the PERMIT FE[ above information is correct. l agt'ee to Lromply with all County ISSUANCE FES ordinances a d State laws relating to bu[7dinF construction and heroby horize re ntaLives of this Count-,, to enter TOTAL FEE 25,00 UP o v m tio propertl fur inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS*CObIPENSAT]ON DECLARATION CE 87 5(11-841 MISCELLANEOUS APPLICATION CE 876 - 1 hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure. or a certificate of Woriters'Cornpenation 4-asurrrnce,or a certified copy themf(Sec. 3800,Lab.Q. or Policy No. Company FOR APPLICANT TO FILL IN BUILDING DDR[ wDwsS Certified copy is here furnished- sulr�lNa PCA LriY P. �' %x ElCertified copy is fDed with the county building inspections LOCALITY�� RC AR e,r department. G l CRacc ST. f}alc Applicant NKA RKlT DISTIII NO. G UP TYP[ P cKSSKD ■Y CROSS ST. CONfT. (-ERTIFICATE OF EXEMPTION FROM WORKERS' LK GAL MA' Ud a„w^Y COMPENSATION INSURANCE D[SCRIPTION LOT NO. [LOCK No (CIwCLL) STAT[ MAJOR SKCOND LOCAL NO. OF ■LDGS. (Tltis section nee,( not he completed if the worst involved TRACT NOH ON LOT USK ZONK SP[CIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) U■K or / SIZK OF LOT [X ISTIN0 I-Dal. O 1 certify that ithe performance of the work for which this perrltit is issued, I shall not employ any person in any manneV-K owNe^ Of building D /S o vl as a, become allyect to the Workers' Compensatlon laws MAIL /I OCCUPANCY GROUP Appilcmnt T[L. t►� 2 OCCUPANT LOAD O NOTICE 1.0 APPLICANT: If, after making this Certlf-scate of crry. f No• ✓g v Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: (:onrpensalion provisions of the Labor Code, you must forth- with comply with such provisiuns or this permit shall be TIIAIL[R USe.f-1 aeoLoaY IIISPKCTION No Spec. Knowl. Recited revoked. Panic Devices OCCUPANCY INSP[CTION I WENS1'D CONTRAIITORS DECLARATION I herrby affirm tint I am licensed underpprovlflO ns of Chapter SAFKTy P[w Mrr � (LIST ITKMS ■[LOW) NO. OF KXITS 9 (colnntencirs with Section 7000) of Dtv iv 3 of the Busi- ness and Profession, Code, and my license Is in full force anLc Name Of business PARKING PRoviDCD effect. IrACK■ ^[o'D I.iiensi �nitthcr _ __- _ - Lic. (lass ° LIMITED TIME USE OATS DA ft Contractor _—_-- Dale .wow( Poi I am exempt from the licensing requirements as I am a N 3 P C CTO R'5 licensed architect or a registered professional engineer ■IZK OF No. of SIGNAT Re acting in my professioml capacity (Section 7051, Bus- cXISTING ■LDa. ■ro^'[' Inez and ProfessionsCude). Pw[scFINAL APPROVAL NT uec or BUILDING �-� I.ic.or Reg. No. ___-. .- _ [Jose q HOME O%VNFR-ntlILDER DECLARATION No. or A14D USa BUILDINGS n �{y l ON LOT AND us[ I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions(.ode): NO. PARKING ' 1 ■PACKS PROVIDKa NO FIE I- 1, as owner of site property. n•W do the work and the structure is not intended or offered for sale (Section 1044,Business and Professions Code). CONSFRIICHON LENDING AGENCY PROPOS[D us[ or BUILDING (�(�]-��l]1 f7,`1V,/,q ` I hereby affirm that there is a construction lending agency 1 x'111 for the performance of the work for which this permit is issued(Sec- 3097,Civ.C.). Lender's Namtt ------ PROPOSKa MAX. OCC. Lender's Address' _.___. _ . PERMIT FE[ 1 certify that I have reed Ibis appllgtion and stale that the aiwve information is Lo l a6rce to wm ly with all County ISSUANCK FKK ordirmnxs nd State ret,ting to tns lrlg construction, 25 �� and Isere authoriz r ntatives oC County to enter rornr_ FK[ upon lh rve me a mperty for' s ion purposes i�_ EE REVERSE FOR EXPLANATORY LANGUAGE _ 7