HomeMy Public PortalAbout9966 BOGUE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 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 fl-
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING LOCALITY j�
ADDRESS PL /
Certified copy is filed with the county building inspection LOCALITY LL NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO G JTYPE�� OCES D BV
CROSS ST. ' O CON
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP MIGM AY
NO. (cI LE) STATE MAJOR SECOND LOCAL
NO. OF BLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE OF
SIZE OF LOT CMk* EXISTIN 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 OWNER _
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP o
ADDRESS ~
Date Applicant LL'i
NOTICE TO APPLICANT: If, after making this Certificate of CITY �i�C
TEL
y OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION 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.
deemed revoked. �/
OCCUPANCY INSPECTION DU Panic Devices
LICENSED CONTRACTORS DECLARATION
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. PARKING REQ D D PROVIDED
SPACES
License Number Lic. Class l i 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 IGEC TURFi
S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
C
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date -
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS d�v i
ON LOT AND USE -� � }•
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi 'L G -f Fici•I va
ness and Professions Code): NO. PARKING 7 SIM
❑ 1, as owner of the property, will do the work and the SPACES PROVIDED 3307
structure is not intended or offered for sale (Section 1 ITEMS-
7044,Business and Professions Code). TOTAL 43 ® 0
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING j V �I�T•�l c 44 l rt s IJ V 0'!
I hereby affirm that there is a construction lending agency `
CHECK
for the performance of the work for which this permit is ICHANGE .00
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address 1000-11,001 i/18/90
PERMIT FEE
I certify t I have read this application and state that the O'o plc• .,�
above i r tion is correct. I agree to comply with all County ISSUANCE FEE / 0 ��'�� 1 A1tl"�!-1
ordir es nd State la lating to building construction,
an ere auth0 ' e I SentatlVOS Of this County t0 enter TOTAL FEE v
u t ab v- e i d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee at