HomeMy Public PortalAbout9965 BOGUE ST_Building__ WORKERS'COMPENSATION DECLARATION
he by,affirm that I have a certificate of consent-to self APPLICATION-FOR BUILDING PERM
e, aro certificate of Workers'Compenstion Insurance, or
a tifiej copy thereof (Sec 3800, Lab C.) C
`� � COUNTY OF LOS•ANGELES BUILDING AND SAFETY
Polic No.��`Z� Company^
BUILDING
F]
Certified copy is hereby furnished. "FOR APPLICANT TO FILL IN" ADDRESS C .
Certified copy is filed with the county building inspec,- BUILDING
tion departmentADDRESS LOCALITY
NEAREST
Date
Date ,�— Applicant �1�� CITY ZIP CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR '
COMPENSATION INSURANCE 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 ✓�
hundred dollars ($100)or less.) TRACT BLOCK LOT NO NO
TEL , (�►[� _ SPECIAL
I certify that in,the performance of the work for which this OWNER NO '+ CONDITIONS O
ermit is issued, I shall not employ an person in an manner DISTRICT GROUP. TYPE FIRE PROCESSED BY (�
p p Y y p Y i CONST ZONE
so as to.become subject to the Workers'Compensation Laws. ADDRESS � �n A
Date 1 Applicant CITY ZIP ��� STATISTICAL CLASSIFICATION APT JCON(50�
ARCHITECT OR TEL !!'�— V
• NOTICE TO''APPLICANT If, after making this Certificate of ENGINEER � � NO. �
Exemption, you should become subject to the Workers' - CLASS NO _DWELL UNITS H
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with' such provisions or this permit,shall be
deemed revoked CONTRACTOR NO — BK PG, VALIDATION
•LICENSED CONTRACTORS DECLARATIONi� C
I hereby.affirm that I am licensed under provisions of Chapter 9 ADDRESS' O• 'VALUATION
(commencing with Section 7000)of Division 3 of the Business andLIC
Professions Code,-and my license is in full force and effect CITY :- CLASS — $
SQ FTNO OF. NO OF CHECK t•, '
License Number 3� t4 Lic.Class �� SIZE STORIES FAMILIES ONE
�T�A ,��q-�• $ t
Contractor. M►R►� Date '�7—`e'r'r DESCRIPTION OF WORK NEW
❑ :- ADD
I am exempt from the licensing requirements as I am a '—
licensed architect or a registered professional engineer_,_ ALTER FINAL •/D /7� ]7�
acting in my professional "capacity (Section 7051, 4XbAQj1-A REPAIR DATE G a
Business and Professions Code). USE OFA FINAL
EXISTING BLDG t� • DEMOL a By
Lic.or Reg No. Date APPLICANT TEL '
OWNER-BUILDER DECLARATION - PRINT) NO J ` Z -,O 7 3 7 A
I hereby affirm that I am exempt from the Contractor's License v a
Law for the following reason`(Section 7031 5, Business and ADDRESS -% Y!;o 0 0 0 0 1
Professions Code)- PRESENT
F1 I,"
J 7 G 7 5
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 o-o,� '2 7 rj U
7044, Business and Professions Code). , MOVING TEL !� '
CONTRACTOR. NO Q
I, as owner of the property, am;exclusively contracting ,
with licensed contractors to construct the project (Sec- ADDRESS
hon 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$ Permit.Fee Z ZS -
Lender's Address. _
w I certify that I have read this application"and state that the Issuance Fee
abAne
mation is correct I agree to comply with all County Investigation Fee
orand a e ws relatin to buildin construction, 7
omg g Total Fee
ay au rize r res tives of this County to enter
uHilo r rty for inspection purposes
�w SEE REVERSE FOR EXPLANATORY LANGUAGE-
36
ignature of Applicant or Agent Dote - ®S