HomeMy Public PortalAbout10155 BOGUE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(11-84) M I SC EL LA N EO U S APPLICATION
CE 875
I heteby a cert that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or ,
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS
BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING !�1SS E �Q��� T LOCALITY Cov
0 Certified copy is filed with the county building inspection LOCALITYNEAREST
department. TQM l- C ry CROSS ST.
Date Applicant NEAREST DISTRICTN_flfl. OUP TYPE PROCESSED BY
CROSS ST. ECIC ` ,1(/ ��i GONST. / •
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - l `/
COMPENSATION INSURANCE DESCRIPTION LOT No. 3� BLOCK' MAP - MIG.WAY STATE MAJOR SECON OCAL
NO. OF BLDGS. NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USE ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF T
SIZE OF LOT 55D EXISTING BLDG. �Q�IAA
' �--
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER JV07 C k, �' �!V JIL1 I G#AIV
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP 7MAl-
--RJ 4 31
�...�DDRESS 0/,J`1 ��6-(�E s'r,�p r V
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of clrvj{/) (,Le�il 9 y No.B��- �F-�7-^ 7�{�0 %OCCUPANT LOAD O-
rn
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. E]
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
C5P
ness and Professions Code, and my license is in full force and ^ // ��/� -1
effect. Al eiV "COS-61 I-."A/ (US�,vG- eXIs7 J1_JC- PARKING REQ'D PROVIDED
/� SPACES
License Number Lie. Class �F- GN65 it A770 �� GvUs LIMITED TIME USE
Contractor Date 62 0 13 A Go/�f"2p�A 02 �v
DATE DATE
I am exempt from the licensing requirements as I am a !u/'1'�3oU r� EVI.�.E Ole A FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECToR's
TURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES YGNA
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS `
ON LOT AND USE F 7 O a 0 A
I hereby affirm that I am exempt from the Contractor's z •
License Law for the following.reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED 1 •o,e 80.50
structure is not intended or offered for sale (Section
7044,Business and Professions Code). e o o $Q 5 0 0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency O Q O O=$`$
for the performance of the work for which this permit is -
issued(Sec. 3097,Civ.C.).
Lenders Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County ISSUANCE FEE �J
ordinances and State laws relating to building construction,
and here y authorize representatives of this County to enter I V30
TOTAL FEE
upon th� ove-m ntion� erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date