HomeMy Public PortalAbout10529 BOGUE ST_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self "APPLICATION FOR BUILDING 'PERMIT_ �.
insure, or-a certifi;ate of Workers'
kers' Compensation Insurance,
or a certified copy thereof'(Sec. 3800;Lab. C.) COUNTY OF LOS ANGELES BUILDING:AND SAFETY
1,
Policy No. Company
❑ Certified copy isehereb furnished
FOR APPLICANT TO FILL IN ADDRESS =
Certified copy is filed-with the county building inspec- ' ' BUILDING J s� L;
Tion department. ADDRESS I �/ J
Date - -
Applicant CITY ZIP LOCALITY �-
CERTIFICATE OF EXEMPTION FROM WORKERS'. NO. OF BLDGS NEAREST --
COMPENSATION-INSURANCE r SIZE OF LOT NOW ON LOT CROSS ST..
(Thi`; section need riot be completed'•if the permit)s-for one - - - 3 ASSESSOR,
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. uL�•3,_OQ USE ZONE MAP
I certify that in the performance of the work for which this OWNER / NO:4T
permit is issued, I shall not employ any person in'any manner t^ v►� �,� ( SPECIAL �.
so as.to become subject To the W r fs' pensation s. ADDRESS 55'� 7 1 -1CONDITIONS O
3 .
. _ .. ZIP _+_�d i u
Date .� �AiPlicant CITY
NOTICE TO APPLICANT: If, after'm m this Cert fica'Te of ARCHITECT OR TEL: - DISTRICT GROUP TYPE FIRE PRO SSED By,
ENGINEER n 4� 46
Exemption, you'should ,become subject"'�to'*the' Workers' "`'C-6 NO' S CONST. ZONE
Compensation provisions of•the'Labor Code, you must forth- ADDRESS 3'1 L QI/ / •-. - e�
with comply with such provisions or, this permit shall be ~ N
T STATISTICAL CLASSIFICATION APT. CONDO:
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION - -- LIC. CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)ofDivision.3 of the Business andLIC• SEWER MAP
Professions-Code, and my license is in full force and'effect. CITY CLASS BK. I_r PG. ! VALIDATION
SQ. FT. ! NO. OF _ INC. OF CHECK
License Number Lic.Class SIZE (� STORIES 6x'� FAMILIES O�Y�' ONE
\
VALUATION r,
1.4 :2A
DESCRIPTION OF WORK NEW _
Contractor Date
-1 ADD
. v
1 am exempt under Sec. ^ ALTER , n o+ ` •7
B.&P.C. for this reason <
REPAIR ❑ $ Cr 00V f. �. 7
Date: USE OF DEMOL O!_ �,!' m
EXISTING BLDG.
Signature APPLICANT TEL.
1y gPRINT. NO...- FINAL Zr G J n —85� OWNER-BUILDER DECLARATION /
.Aeby affirm that l am exempt from the Contractor's License -DATE
C� 'law for the following reason (Section 7031.5, Business and ADDRESS FINAL
!' Professions Code): PRESENT BY -
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do The work and
the structure is not intended or offered for sale(Section LOCALITY 9 9 4,4 A
7044, Business and-Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the'project (Sec- ADDRESS C o ? G
L
tion 7044, Business and Professions Code). ,
REQUIRED TOTAL-SETBACK FROM EXIST.,
C L v
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH, c.c o { 8
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.
Q Lender's Name LDMA.Ref. #
\ Lender's Address P.C. Fee$ Permit Fee
>
It
I certify that I have read this application and state that The - Issuance Fee- 0 1 J LDMA P/C#
oabove information is correct. I agree to comply with all County I vestigation Fee_
ordinances and State laws relating.to building construction, - Total Fee 7 � LDMA Perm.'# I r11 a-n
u and hereby authorize representatives of this County to enter r� fjI C3
t bove-mentio property for inspection purposes. O O
_
a CH �\
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature'of Applicant or Agent -
'Date