HomeMy Public PortalAbout10103 BOGUE ST_Building_4/20/1992 WORKERS' COMPENSATION DE', RATIIQN
I hereby affirm that I have a certificate of consent'to self
insure, ora certificate of Workers: Compensatian-Insurance, APPLICATION •F S R .�U I L D I N G P E RM'I T
or a c r fi cop thea of (Sec. 3800 '' b'C.) '
P� 12v L. . ✓ . . , y COUNTY OF LOS ANGELES BUILDING AND SAFETY
l.�l Company
+- BUILDING'-
, ❑ _ Certified copy is hereby-furnished. FOR APPLICANT TO FILL IN i ADDRESS {'
Certified co is-filed with the ount 'Idin i s c BUILDING •
py g ADDRESS " Sol `�
_ t
jfic�de, ailment. � CITYZIP LOCALITY'Date Applicant NO. OF BLDGS. NEAREST
TIFICATE OF EXEMP.TION'FROM ORKERS' '• SIZE OF'LOT " NOW ON LOT CROSS 57 "
COMPENSATION INSURANCE• ASSESSOR t
(This section need not be completed if-the permit is for one TRACT BLOCK LOT NC-* MAP BOOK PAGE PARCEL•
.hundred dollai•s'($100) or'less.) TEL :3
. ' •: OWNER O z`� NO 7 USE:ZONE MAP'
I certify that-in-the performance of the work for which this '' NO.
permit is issued, I,shall not employ any person m-any manner ADDRESS �d = •/ SPECIAL d
CONDITIONS;
so cis to become subject to-the"Workers:Compensation Laws. O
CITY , ZIP _ ,a ., U
Date - Applicant ARCHITECT OR• TEL.
NOTICE .TO'APPLICANT:;.If, after makin ihis•Certificate of
ENGIN NO DISTRICT GROUP TYPE FIRE PROCESSED BY
g- CONST. ZONE
Exemption, you should become subject to;the-:Workers'' G i•% iU
Compensation provisions the Labor Code,-you must forth- , ADDRESS �QO — 3 Y CL
with-comply with such provisions or this'permit shall be 1 T 0q j� STATISTICAL CLASSIFICATION APT., CONDO. N
deemed revoked.-. CONTRACTOR .0 C_ i NO.l� �' �! ?.' Z
_ LICENSED CONTRACTORS DECLARATION r,• J • ,L - , LIC �� 22 CLASS NO DWELL UNITS
ADDRES GZ02-' 6�U N J•"
hereby affirm"that I am licensed under provisions of Chapter 9 LIC. SEWER MAP
(commenang'with Section 7000)of.Division'3 of the Business _ '
and Professions Co n my,-Ijcense is m full force CITY. 6 �� CLASS BK PG VALIDATION
j SQ'FT. n NO'_OF' / _ NO OF CHECK
Licerise Number Ltc. Class SIZE ;('(/b STORIES ( FAMILIES ONE
' DESCRIPTION OF WORK NEW ❑ VALU TION t
Contractor`4'f c Date / �+��- LU
` G IO 'ADD ❑ , Y
0 I am exempt under Sec. (p_ 7
B.&P.C. for this reason' «� 'k ALTER ❑
• � - G � REPAIR ❑
Date: USE OF
EXISTING BLDG DEMO"" ❑
Signature FINAI
APPLICANT TEL
'(P
OWNER-BUILDER•DECLARATION. '(PRINT).
NO
I hereby affirm that I am exempt from the Contractor's License DATE
Low
for The following reason`(Section 7031.'5, Business"and ADDRESS ' FINAL -•• + t ="-`
Professions Code): PRESENT By 7, tBUILDIII „
I, as owner•of the property, or 'my•employees with ADDRNG
ESS 1- -�' ;'` r --.•
- wages as their sole compensation,will do the work and «���� ��
the structure is not intended or offered for sale(Section LOCALITY
7044, Business'-and Professions-Code-) MOVING TEL ,_,•
` ❑ I, as owner of The property, y 9' CONTRACTOR NO ,
p p y, am exclusive) coniractiri L ;i ty
with licensed"coniractorsrto construct the project-(Sec- ADDRESS
tion 7044, Business and Professtons Code.)
,-REQUIRED TOTAL SETBACK FROM EXIST.
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'Ormit.is issued P L' y:
(Sec 3097, Civ. C.). SIDE
Lender's:Name' J
'm � •• LDMA Ref # _
P C'Fee$ Permit Fee ,
Lender's Address
I certify that I have read'fhis-application and state that the Issuance Fee �/' / S LDMA P/C#
g above information is correct.•1 agree to c ply with all County Inveetigation'Fee ;��
d ordinances and State laws relatin o ilding construction, Total Fee.. LDMA Perm #
a and he�eb a thorize represe _ i- of this County to enter
upon thea tinned r_ty for mspe ti ri-7urpoes. ”
SEE-REVERSE FOR EXPLANATORY'LANGUAGE_ ,
• Signa re of.Applicant or Agent Dote - - '