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Home My Public Portal About9620 GIDLEY ST_Miscellaneous__ woRKERs'COMPENSATIONDECLARATION CE 876 (1'14) MISCELLANEOUS APPLICATION � CE 876 I hereby aifnnn,xhat I have a certificate of consent to self CONY OF LO&.ANGILES BUILDING AND SAFETY DIVISION inauro,`�rti�te of Workers'Compensation Insurance,or a Certj£1ed 11 y thereof(Sec.3800,Lab.C.). Polio No. CompanyFOR APPLICANT TO FILL IN BUILDING ADDR[S■ Certified copy L hereby furnished Bno iss 9620 GIDLFy LO CA LrrY Certified copy is filed with the county building inspection CALITY department. TEMPLE CITy CROSS ST_ Date Applicant N[ARKSTTEMPLE CITY $LVD• DISTRICT XO. 6 OUP TY r C[//[D ■Y CROSS ST. 'of _ CON CERTIFICATE OF EXEMPTION FROM WORKERS' LXGAL COMPENSATION INSURANCE )K SCRIPT ION LOT XO. ■LOCK MAP HIO HWwY ND. (tint L!<) STAT[ YAJOR S[CO ND LOCAL NO. OF ■LDGS. section II00d not be COIDpLBtbd if the HOLY involved TRACT NOW ON LOT US[ SOX[ OP[CIAL CONDITIONS by the permit is for one hundred dollars (;100) or leas.) USK OF � SIZ[ OF LOT [XI/TING BLDG. I certify that fn the performance of the work for which this o permit is issued, I &hall not employ any person in any manner oZN[ fR so as to become subject to the Workers' Compensation Laws FAR �, OCCUPANCY GROUP °C - o ADDR[■ Date Applicant a NOTICE TO APPLICANT: If, after moping this Certtflcate ofc —.418 444 n ts� Compensation OCCUPANT LOAD �y on, you should become subject the Workers- APPLICATION FOR ZD – 7 – EXIT HARDWARE: Compensation provisions of the Labor Code,, you must forth- with comply with such provisions or this permit ¢hall be L] [JNo Spec. Knowl. deemed revoked. TR AIL[R U/[ G[OLO GY IN SP[aTION LICENSED CONTRACTORS DECLARATION OCCUPANCY IN/PXCTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of ter ■AF[TY P[RYfT (LIST IT[Y■ B[LO 1•) 9 (commencing with Section 7000) of Division 3 of the Bu ❑ NO. OF [XITS new and Professions Code,and my license is in full force and Name of business : effect PARKIN G SPAC[S R[q•D D PRO,. License Number Lia clan, EL MONTE IRON 9 METAL CO. INC. Contractor T1.,♦� LIMITED TIME USE Contractor Date DAT■ OATI I am exempt from the licensing requirements as I am a "RD"' TD' NOD FEE licensed architect or a registered profbuional engineer /Iz[ OF NO. OF INSP[CTOR ■ acting In my profeasional capacity (Section 7051, But [XIerING ■LD G. STORMS RIGNATUR[ mesa and Professions Code). FINAL APPROVAL � - Lia or Reg.No. DR[e[nr u/[ of BUILDING ate .I37 VACkff HOME OWNER-BUILDER DECLARATION NO. OF [XISTING BUILDINGS ON LOT AND USX I hereby affirm that I am exempt from the Contractor's r 1 IO License Lew for the following reason (Section 70315, Buss- near and Professions Code): NO. PARKING El I, as owner of the property, will do the work and the SPA G[S PROVID[D p structure is not intended or offered for sale (Section 70-44,Business and Professions Code). CONSTRUCTION LENDING AGENCY ROPOSKD US[ 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 PROPOSED WAX. OCC. Lender's Addreu I certify that I have read this cep cation and state that the F[RMIT F[Q 25 .00 above information Is correct I to comply with all County IsaUANCH FISK ordfnances and State laws to building construction, and hereby authorize r tives of this County to enter TOTAL F[Q 25 • 00 lipon the above-men p for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE d/s ,7 Signature of Permittee Date y II� GYORKERS'COMPENSATION DECLARATION CE a;8(11-84) WSC'ELLAN EO U S APPLICATION 1 I hereby afffim tbat I have a cartfflnte of consent to sekf insure, or a cortneate of woikare Compensation[nuance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u a certified thereof(Sec.3800,Lab.C-). I Poltcy No. y RPn((hI J E 74rlPmn4tv FOR APPLICANT TO FILL IN ■u ILDI1f Na w AD DR[ 'v ❑ Certified copy is hereby furnished. g wnDBu1LDRcNaIas 9620 GIDLEY ST. LoCAUTY I l ; ❑ dCerdned ep enz� L wed with the county traildtng tn:p°crl°n g '- ---'-r.`TEMPL E CITY CA. CFKAtOA Sx fT ST. Date Applicant NSwRcrr DIS. a ��. ;Fur Irypic OC=ffca ■r CRo[S ;i (/ ,�Jf CERTIFICATE OF ECE=ON FROM WORKERS' LcCIA L COMPENSATION INSURXINCE O[SCRIPTIOn LOT n0. ■LOCK r.Ar MIU N1►AY No. (clwcti) fT ATt MAJOR i[CO ND LOCAL NO. Or BLDGS. _ (This section need not be completBd if the work involved TRACT NOh ON LOT USK ZON[ SPKCIAL CONDITIONS by the permit is for one hundred dollars (5100) or leas) a■e OF �� I fIZ[ or Lor [xlfnna Bina. ?" I terrify that in the peaotmsna of the work `or Which this a _ go ai is issued. I subject not employ any-er parson s any manner o.NCR so as m became snbject to the Workers Compensarion Laws NAIL OCCUPANCY GROUP g A❑.Rcff _ Date applicant — NOTICE TO APPLICANT: If, after making :his Cenificate of X CITY A AVE DOL OCCUPANT LOAD - Ezemption, you should become subject to the wULiLaIS — Compensation provisions of the Labor Code, you must forth- ' AFPLICaT10N FOR EXIT HARDWARE: I with comply with such provisions or this permit snail �e -RAILiR ui[ a[OL.DcY INZP[CT:ON No Spec. Knowl. deemed-evoked- LICENSED eemedevoked. _ LICENSED CONTRACTORS DECL.3R-ITION OCCUPANCY !N5 PKC-1 Panic Devices I hereby affirm that I am licensed underpIO�75iO us o Charter SAF[rY �[RMrr LIST ITKMS ■[LOW) I 9 (commencing with Section 7000) of Division 3 of the Bus No. or [xlTs nets and Professions Code. and my License is in dill force and LI effect. PARKING R[O•D rR OV10[D !►ACI1 License Number Lit. Class LIMITED TIME USE Contractor Dau I am e-.empt from the Licencing requirements as I am a v I Licensed architect or 1 registered proIessionnl eer 711[ OF No. OF IN IG CTO R'i LLg1SC �n�ln !I G N A T U R I ? acting in my professional capacity %Section 7051, Bus- EXISTING BLDG. 9TORl[7 in=and Professions Code)• T Ut[ OF ■UILDINa FINAL APPROVAL � �R E7[N Lic.or Reg.No. Date I N1=I FEE HOME OWNER-BLLILDER DECLARATION NO. OF [XifTINO BUILDINGS D „nom ON LOT AND ui[ I hereby arm that 11m emp-c from the Contractor's tT•I � i License Law for the following reason (Section 70315, Busi- ness and Professions Code): NO. PARKING 5 1 �;L 1, as owner of the properry, will do the work Ind :he s�AccS rRovlD[D structure is not intended or offered for sale (Section i 7044,Business and Professions Code). y CONSTRUCTION LENDING AGENCY g wRO wOf[O Uf[ OF 9UILDINa I hereby nfirm that there is a construction lending agency LIGHT MANUFACTURING I for the performance of the work for which this permit is issued.(Sm 3097,Civ.C.). Lender's Name PROPOf[D MAX. OCC. L ender's Ad K--Ie P[RMIT Faa 25.00 1 certify ation and state that theabove mf co tripply with all County IasUANCK F[[ orobuilding �rlstnaction, and he aof this CCounty tD enter TOTAL Fast 25.00 upo ar_ape"_ pn�os� SEE REVERSE FOR E-,CPL.AJNATORY LANGUAGE XX SiI azure of P-rttirt" Dau