HomeMy Public PortalAbout9925 BOGUE ST_Building__ a WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING• PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) `� t COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.. Company 757,472;- /'til/" i
1 BUILDING
El Certified
Certified copy is hereby furnished. . FOR AP Tne FILL IN ADDRESS "� li �
❑ Certified copy is filed with the county building inspec- \ BUILDING 2� S't• C.E G�
ql
tion department. ADDRESS G T /� Q
45 K1 ITY �+jN Lam/ LI1 ZIP '717v0 LOCALITY
Date Applicant f f NO. OF BLDGS. �/ NEAREST �t_ A
CE TIFICATE OF EXEMPTION FROM WOR RS' SI E OF LOT 1 1 0 NOW ON LOT ONc_ CROSS ST, gP}�el* 114 A M-1
COMPENSATION INSURANCEASSESSOR
(This.section need not be completed if the permit is for one TRA T BLOCK LOT NO. MAP BOOK PAGE PARCEL I
hundred dollars ($100) or less.) TEL
v OW ER Y &kaCV La NO. USE ZONE NOP •,/ f/oZ�
certify that in the-performance of the work for which this SPECIAL }
permit is.issued, I shall ncwemploy y pe on in any manner ADD ESS 2 OU / CONDITIONS a_
so as to become subject to the Worker Comp sation Laws. �� Ov
CI � • C4T ZIP U
Date Applicant A HITECT OR C. TEL DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT:, If, after making this Certificate E GINEER . �js0 NO. '6CONST. ZONE �
Exemption, you should become subject to the Workers' �� s• ��� �O �/ .� V 3 w
Compensation provisions of the Labor Code, you must forth- ADDRESS 4 C7,9MeL a V N
with comply with such provisions or this permit shall be. q/r} ` ,r�/ TEL. (p(Sg(3y- STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR (r�1S1 �V NO. l J —
LICENSED CONTRACTORS DECLARATION � i� �2 , fs LIC. + 9�1 p• p CLASS NO. '::q UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS r` NO. SEWER MAP
(commencing with Section 7000).of Division 3 of the Business LIC'
and Professions Code,and my license is in full force and effect. CITY CLASS
BK. PG.
VALIDATION
_ SQ. FT. NO. OF NO. OF CHECK
License Number O 1- Lic. Class SIZE d STORIES ' FAMILIES ONE
VALUATION -
Contractor�i'� v` Date DESCRIPTION OF WORK NEW $
-t' gATJ'1
?- g ItooM Apd�Ttal�l ADD 60.
❑I am exempt under Sec. l� - - •:� -
E p 1 YWCe Av✓bi�oN ALTER ❑ a I: 1•_ J
B.BP.C. for this reason REPAIR ❑ ;-1T`1 79-3-
r1 .�: 9 II
USE OF �_� trr
Date' EXISTING BLDG. ,J,j! H DEMOL ❑ CHECK
} _:
Signature APPLICANT, $
,t�' e' 'SfO . No:2E3S � FINAL n
PRINT Z, 0 �f{} �c� f.'=f t3 a� i;l.i
WNER-BUILDER"DECLARATION I Z S..S/}�/ 4AIIIEL E3�o. DATE Z Y [ =_Er.� :_�
I hereby affirm that I am exempt from the Contractor's License /
Law for the following reason (Section 7031.5, Business and ADDRESS L° q, ore, FINAL
Professions Code): PRESENTBY
BUILDING 1='
❑ I, as owner of the property, or my employees'with ADDRESS - -. n a •-e
-1 t
wages as their sole compensation,will do the work and , ' •:.� F+::t `��i
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL.
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed-contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
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.
Lender's Name,
P.C. Fee$ -0. 7- Permit Fee P �9 LDMA Ref. #
Lender's Address
o I certify that I have read this application and state that the Issuance Fee LDMA P/C# ,-
0
8 above information is correct. I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee 7 LDMA Perm. #
¢ and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE *•�'
V� ature of Applicant or Agent Date