HomeMy Public PortalAbout10053 BOGUE ST_Building_6/27/1988 •;. WORKirmERS' COMPENSATION DECLARATION
-insure or°afcertifi�e of Wo ke s've a Compensationificate of ensuran ent to lf A P P L I CAT•I O N F-O R BUILDING 'PERMIT
or a certified copy thereof (Sec. 3800, Lab-. C.) +, COUNTY OF LOS.ANGELES ' BUILDING•AND.SAF TY'
Policy No. Company - _
� t
Certified copy is hereby furnished.' `'*" FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy'is filed with the county building inspec- BUILDING -
ag aa
tion department. ADDRESS p0SJ444 oe:+•/�S� `[�
Date Applicant CITY /r/LE C-�IL.- zip r7 IN " LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS. - NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST
(This section need not be completed if the permit•is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT.NO. MAP BOOK' PAGE PARCEL-'
OWNER / E LA �2 TEL. 5.7 7 USE NE MAP.'
I certify that;in the.performance of the,work for which this NO
permit is issued, I shall riat employ,ciny person in any manner ?— /-'�-' SPECIAL '
so as to become subject to the Wor Compensation Laws. ADDRESS/1005:3/1 A96UE 511,1 - ` -p�� CONDITIONS O
lds-"(J`r�L CITY; M/'4F C C 4 ZIP
Date Applicant ARCHITECT OR TEL
NOTICE TO APPLICANT: If; after making this Certificate of ENGINEER '-r— NO DISTRICT G�—Tco PE FIRE PROCESSED BY O
Exemption; you should become subject to the' Workers' /1 NST ' ZONE LU
Compensation provisions of the Labor Code,'you must forth- ADDRESS W
with comply-with such-provisions or•this permit shall be TEL ' STATISTICAL CLASSIFICATION APT. C DO. N
deemed revoked. CONTRACTOR NO Z
LICENSED CONTRACTORS,DECLARATION LIC, - -CLASS NO. DWELL UNITS
I hereby affirm that.l am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with,Section 7000)of Division 3'of the Business and LIC SEWER MAP
Professions Code;and my license,is in full-force and effect. CITY CLASS BK VALIDATION
SQ.,FT. NO. OF . NO. OF CHECK
License Number• Lic.Class 'SIZE STORIES FAMILIES ONE
Imo, VALUATION
Contractor Date DESCRIPTION OF WORK AV j �0�� NEW ❑ $
y- ADD ❑
I am exempt under Sec. ) b Q�✓ l��J ^ ❑ �'
ALTER
B.i3P.C. for this reason REPAIR ❑ :
'Date- USE OF DEMOL
EXISTING BLDG. ❑
Signature �Gszr / � APPLICANT TEL FINAL`
PRINT IL14 211 DE!�9 JB�,�•N
•WNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt'from the Contractor's License //aa
Low for the following-reason (Section 7031.5,'Business and ADDRESS /UD wE v= ' L. FINA
• ' Professions Code): = �• - - By 10
rBUILDING
1, as owner 'of the property, or my employees with ADDRESS ?„4 #,o Ole,* o
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale(Section LOCALITY ;�, I _,-3'3 0-0
7044, Business and Professions Code). MOVING - TEL.
CONTRACTOR NO. U.
•� I, as owner of the property, am exclusively contracting ,�, � � - o 0 0 3 3 Q'O,
with licensed contractors to construct the project (Sec- 'x ADDRESS 2 +8 8
tion 7044, Business and Professions Code). .
REQUIRED TOTAL SETBACK-FROM
CONSTRUCTION LENDING AGENCY SET BACK -YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT `
the performance of the work for which this permit is issued P L. -
(Sec. 3097, Civ.C..). SIDE
P.L.
Lender,=s Name CDMA Ref
P,C. Fee$ Permit Fee °•��
m Lender's Address
I certify that I-have read this application and state,that the Issuance Fee d J W CDMA P/C.#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building,construction,
representatives of this County to enter - Total Fee - . j CDMA Perm
o and hereby authorize
m upon he above-mentioned pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Y Signature of Applicant or Agent- Date. _ - -