HomeMy Public PortalAbout10641 BOGUE ST_Miscellaneous__ ,�._... CE 875 WOEI.`ERS'COMPENSATION DECLARATION
CE 875 (11-84) M I SC E L LA N EO U S APPLICATION �I
C �
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 certified copy thereof(Sec. 3800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING1126411 6 ADDRESS v
Certified copy,is hereby furnished. 8u1LDING LOCALITYAl
ADDRESS
FCertified copy is filed with the county building inspection LOCALIT r NEAREST
department. CROSS ST. ,
Date Applicant NEAREST DISTRICT NO. G 'UP COPS PROCESSED BY
CROSS ST. 3
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP Ric Hw nY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
I �/ "5+ NO. OF BLDGS.
(This section need not be completed if the work involved T T `, v NOW ON LOT ` USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) _ �bX USE OF
/ /I
SIZE OF LOT O EXISTING BLDG I
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 OWNS n� y
so as to become subject to the Workers' Compensation Laws. MAIL ,N _dCCUP�ANCY,s8R\OU,P_ —
ADDRESS \•'�\.�,:�` 1„a\��..� i \1 'J,I -•, O
Date Applicant T �l � � � w
NOTICE TO APPLICANT: If, after making this Certificate of c ` N �_Lf��O OCCUPANT LOAD Z
Exemption, you should become subject to the Workers' APP ATION 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. Knowl. El
deemed revoked. ,
LICENSED CONTRACTORS DECLARATION occuaANCY INSPECTION E] 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 i
effect. PARKING REQ'D E� PROVIDED
SPACES
License Number Lic. Class
�., LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
0 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code).
7n
PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ZZ
7 �-2 A
ON LOT AND USE '
I hereby affirm that I am exempt from the Contractor's ,e 30
License Law for the following•reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING \ (l °10 $0 5
SPACES PROVIDED
I, as owner of the property, will do the work and the C `� e'e-.C$•Q�5`0
structure is not intended or offered for sale (Section �'S �.\�':�`� '�' \ �t �'> ,'j` �' �\`
�� \
7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
I hereby affirm that there is a construction lending agency \�� �>�• �;J '��;''.,L`��ti�a < <�l\��, '
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
n the above-mentioned p perty r i ection purposes.
c SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignature of Permi tee Date
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