HomeMy Public PortalAbout9919 BOGUE ST_Building__ WORKERS'COMPENSATION DECLARATION
I hereby affirm'that,I have a certificate of consent to self + •�4
insure, or a certificate of Workers' Compensation Insurance, AI+'P L I CAT I O IV FOR. '�dJ I'L'D I N.G- P E RM'IT
�• ora i},e�d c py l�reof (Sec o0, Lab. 8 ` t- '
� L6�-�5. . tate ampensa`tlon COUNTY OF LOS ANGELES BUILDING AND:SAFETY
Policy.No company ins Iran' F rid
❑ BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO'FILL IN ADDRESS " G;
�. Certified copy is filed with the coun building inspec- • ' BUILDING "•n
tion deportment: ADDRESS' 9919 BO Ue St..` LOCALITY
i NEAREST
te• 8-12»83 Applicant.
Cit City' zip ':.917e80. - CROSS.ST
CERTIFICATE OF EXEMPTION OM ORKERS' NO. OF BLDGS ,.• ASSESSOR "
COMPENSATION,IN UR CE SIZE OF LOT .NOW ON LOT MAP BOOK " PAGE' PARCEL
(This:section need not be completed'if the permit is for one r�/' USE ZONE MAP '71 Q't^/
hundred-dollars ($100)or less.) TRACT �'J BLOCK. LOT NO. NO, r d K
TEL P�i SPECIAL }
owNER-Ral "h Erickson " N0Z87-3340. a ,` 'CONDITIONS •• C."
' I 'certify that in the performance of The=work for which this DISTRICT GROUP TYPE FIRE PROCESSED BY 'O
permit is issued, I shall not.employ any person'in any manner ADDRESS 9919 Ei Ue St.' CONST. ZONE V
so,as to'become subject to the Workers'Compensation Laws. 10 ,• ; - ' ;'.
CITY Templ-e-`City. zIP, ' 9'178Q ' - O.
Date" Applicant STATISTICAL CLASSIFICATION APT CONDO V
NOTICE'TO APPLICANT: If, after, making.this Certificate of ARCHITECT OR TEL
ENGINEER• N ri .No`'. CLASS NO DWELL UNITS us
.Exemption, you' should become subject t6-the Workers' - -
.''Conipensation.provisions•of the-Labor Code,,you must forth' ADDRESS - SEWER MAP
witli comply with such provisions-or.this- permit shol6'be
deemed revoked. TEL BK. PG 1yALOATION• -
CONTRACTOR.�United�Roofin -�C®uo..:223-4081 ja� .
LICENSED CONTRACTORS DECLARATION' LIC:„
I hereby affirm that I am licensed under provisions of Chapter 9_ ADDRESS lH2l Dal 5t. NO 137650 . VALUATION
(cominenungwith Sectio 7000)of.Drvisioi5 3 of the Busmess.and LOS Angeles S 90031 LIC C w39 3 9
Professions Code;and m license is in full force and effect. • CITY' CLASS 2 4..00
L
SQ.,FT. NO OF N0—b F CHECK
License Number 13 650 Lic.Class C"-39 SIZE STORIES FAMILIES• ONE'
NEW ❑
Contractor ate 8-12-83. °•, DESCRIPTION OF`WORK "
❑ I am exem t ��d sec. reroofin -`with 3-tab fiber•- ADD ALT
ER
FINAL
B:BP.C. for this reason lass shingles over' tear—Off I ❑ DATE,
REPAIR
Date:• USE OF ❑ •FINAL i`..�• '
EXISTING BLDG.. re'sldente DEMOL
By'
Signature"
APPLICANT TEL ' "
` = OWNER-BUILDER DECLARATION PRINT United Roofin CO. ,N6Z23�408'lr ti
I hereby affirm that Fam exempt from the Contractor's License ! .
Law for the following reason (Section 7031.5, Business and ADDRESS1H21Dal "St. LOS 'Angeles 90031'r ►-.Professions Code): PRESENT
'•-���^
BUILDING
❑ ^"I,-as owner of the property,, or 'my employees with
ADDRESS,, 5 0 0A.'
wages as their sole compensation,will'do the work and
LOCALITY + • ' y t '
the structure is not intended or offered for.sale(Section :, # o'o o- o o,
7044, Busihess and Professions Code): r MOVING TEL "
❑ CONTRACTOR 'None NO.
I, as owner of the property, am exclusively contracting ' ',2 o.'4 3,00,'•';'`
with licensed contractors to construct the p'rolect'(Sec- ADDRESS•' r'
tion 7044, Business and Professions Code). s. P..- 0'4 3;0,.0 v
REQUIRED'. -'TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK _ YARD, HWY . PROP LINE WIDTH'
- _ 0 ,08-83
"Thereby offirrri 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 _ • _
r. a
Lender's Name
Lende'r's Address Y P.C. Fee$ none Permit Fee 32.50
> : -;_• _ . '. , _. ... __ "- 10. 50 • .. . •. _
I certify that I'have read this application and state that the•; Issuance Fee -
a above information is correct. I agree to comply with all County Investigation Fee --43. 00
$ ordinances and State laws relating to building construction; Total Fee ~
u and hereby thorize representatives of this County to enter
m upon,—C e-me coned property for inspectionpurpose ;
a ' d SEE REVERSE FOR EXPLANATORY LANGUAGE
Signal ' of Applicanvor Agent ; Dcife