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HomeMy Public PortalAbout10053 BOGUE ST_Building_7/5/1988 t_ hOWE�R:.QjMs'ENSATION DECLARATION r' I 1,racfnfificatI haver certificate of consent to self APPLICATION FOR. OVILDINGPERMITure, or a certificate of Workers' Compensation.lnsurance,or a certyfied copy thereof (Sec. 3800, Lab. C.) • COUNTY'OF LOS ANGELES BUILDING ANDJSAFETY +;I PolicyNo.�• Company -_ - ❑.. Certified copy,-)§hereby furnished :• FOR APPLICANT TO FILL IN BUILDING in© awz ADDRESS ((ll Certified copy'is filed with-ihe county building-inspec- "` - BUILDING /I C I -+- tion'department = ADDRESS DVJ�1� �D6L Date '• Applicant,i CITY LM/"L C- C-1 / VI ZIp .. .- _ r• _ Me) LOCALITY 1 r CERTIFICATE OF EXEMPTION FROM WORKERS' .' NO-OF BLDGS. _ NEAREST- COMPENSATION INSURANCE ••�. �� _ �'•y• �� ' (This section need not be completed if-the-permit is ionone - -- ASSESSOR., TRACT BLOCK LOT NO MAP'BOOK'`. -'PAGE., PARCEL ;hundred dollars ($100)or less..) ,: i. i TEL. f� p�^ USE ZONE MAP - OWNER AI' 11 20 � E '7^ P�O 5,77 71J.J, I certify thai in the performance of the work for` which this NO. >'t_.:;•:_ permit is issued, I shall'not employ any person in any.manner �t / SPECIAL' - -- --- d Iso'as•to become subl'ect-to the Worke s'Compensation`Laws. -ADDRESS-100 Q C•-0 E-- - fig� - I CONDITIONS 40 CITY_7_ / CMP4 _G/_- Cl7ZIP Datel- Applicant Ltr; '_ 'NOTICE TO' APPLICANT: If" after'-making tliis Certificate of ARCHITECT OR TEL _DISTRICT GROUP',TYPE FIRE •_ ,_ P C SED,BY 0 ENGINEER NO CONST. ZONE `~ Exemption;'you-should •become subject'+ta,the Workers' �� f/ ;tV Compensation'provisions of the-Labor Code,'you must forth- ADDRESS ��� _ Y 1.;3»_ d with, comply,with such provisions or.this permit shall be" t y deemed revoked. — TEL - STATISTICAL CLASSIFICATION APT CO DO + -Z CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION -- --.•• - _ LIC _. CLASS NO. DWELL UNITS I hereby affirm,that I am licensed under,provisions of Chapter 9 ADDRESS '' NO. i (commencing with Secfion 7000)of Division 3 of the Business and .- _LIC -- SEWER MAP Professions Code, and my license is in full force'and effect. CITY CLASS BK. ' ' -VALIDATION SQ FT. NO.OF _ NO OF _ CHECK License Number Lic.Class SIZE STORIES' FAM111ES - ONE ! - i %. .,•, VALUATION DESCRIPTION OF WORK NEW._ _❑ Q i Contractor DateA _ ❑ `$ ./� )�Q/_-L.1I. ADD ❑ I am exempt under-Sec. 'j ALTER B.&P.C. for this reason TW-0 WA LL S AI DAMP, A iV,/V. �K/ ❑ s - - -- REP.AIR Date- i' USE OF ? EXISTING BLDG DEMOL ❑ Signature ' . - ' APPLICANT - TEL - - FINAL OWNER-BUILDER DECLARATION PRINT' 'NO DATE I hereby affirm that I-am exempt from the Contractorls License _ f Law for the following'reason'(Section 7031.5, Business and ADDRESS FINA Profess ioris'Code). PRESENT - - By.' y, BUILDING -• ' _ ws ^. 1711. I, .as owner of the property, or my employees with ADDRESS 77 �- wages as their sole compensation,will do the work and ' the structure is not intended or offered for sale(Section LOCALITY ;9 6 2-9.2 A; ` 7044,•Business and Professions Code): MOVING TEL - +1 I, as owner of the property,-am exclusively-contracting CONTRACTOR NO t # ? • • • •,1 + ' e, _ ,y . ` • - with-licensed contractors to construct the protect (Sec- "- � ",•' •- - " ' - - -- •. _ -L�. �.-� Y• :�"�''-4 a-5 0 "•_'; tion 7044,-Business and Professions Code): ADDRESS _ r �� REQUIRED. _.TOTAL SETBACK,FROM- _ T; a -_' z �:, t. ,,'> r,.L--,. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH • o • 4 Q rj,0-� ' I hereby affirm that there.is a construction lending agency for FRONT i'.' %i:r• yr rr.• ti the performance of the-work for which this permit is issued p U - -- _: _ _ _ . _ _ ..,_ �:_. - - 0 1,.0(�;,8 ].._-i (Sec. 3097, Civ. C.) SIDE P L. + Lender's Name - LDMA Ref. # � •• - -- -• - P.0 Fee•$ .- .-- - Permit Fee L'ender's Address -I„certify that-I have read this application-and state that the .. __ Issuance Fee, _LDMA P/C# - i ' a above information is correct. I agree to comply with all County Investigation Fee ordinances and State-laws relating to building construction, u and hereby authorize representatives of this County to enter = +Total Fee �/ L LDMA Perm # he above-mentioned property for inspection purposes. ! - i o SEE REVERSE FOR EXPLANATORY LANGUAGEigS -Signature of-Applicant or•Agent-•• - Date