HomeMy Public PortalAbout10542 BOGUE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
CE 875 (11-84)
I hereby affirm that i have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a ceilified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
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ADDRESS
Certified copy is hereby furnished. BUILDING /65 L LOCALITY G'
ADDRESS
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CQ- �(J CROSS sr.
Date Applicant NEAREST DISTRICT NO. OUP TYPE 1P�ED BY
CROSS ST. ;, CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ' _ ,5 '
COMPENSATION INSURANCE DESCRIPTION LOT NO. 19 K MAP � HIGHWAY STATE MAJOR SECOND LOCAL
NOOF BLDGS.
NO. ,\ (CIRCLE)
/y
(This section need not be completed if the work involved TRACT ���/ NO.W ON LOT ' USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF �/� �y
SIZE OF LOT EXISTING BLDG. hos;," d
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 s�
. Fe
ttele/a6&1
as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP• ADDRESS 4 L BO S�' O Applicant W
rEL. G OCCUPANT LOAD
NOTICE TO APPLICANT: If, after ma ing this Certificate of CITY No. L� N
Exemption, you should become subject to the Workers' z
APPL CATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth _
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know].
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
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
ness and Professions Code,and my license is in full force and
effect. 1'1 I_j_ e _ n1e� tor
PARKING
E
SPACES RQ'D PROVIDED
License Number Lic. Class M6 d I i I�
LIMITED TIME USE
Contractor Date 1 DATE DATE
FROM: TO:
0 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPE TORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. so STORIES SIG ATURE
inessand Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date
PRESENT USE OF BUILDING
S I rtfe �l vn
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS r�fiJ
ON LOT AND USE ■T
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- V110$0,`ill
ness and Professions Code): NO. PARKING Mc
0 I, as owner of the property, will do the work and the SPACES PROVIDED I ITEMS
structure is not intended or offered for sale (Section TOTAL '230 r -i+c
Iry
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK PROPOSED USE OF BUILDING C80■93
�l
I hereby affirm that there is a construction lending agency CHANGE ■
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name 0000-0001 6/27/89
PROPOSED MAX. OCC.
Lender's Address 4200 I AM 8:58
I certify that I have read this application and state that the PERMIT FEE Q
above information is correct.I agree to comply with all County ISSUANCE FEEj 0
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon e above-mentioned pro erty for inspection purposes. '
�1(l , � � a���, SEE REVERSE FOR EXPLANATORY LANGUAGE
S' nature of Permittee Date