HomeMy WebLinkAbout1370 VALLEY VISTA (7) . r�.�„"�. '' �
WORKERS'COMPENSATION DECL4RATION . �
y 1 hereby affirm thot I have a te�fificate of consent fo self APPLICATION F4R BU{LDING PERMIT
insure,or a certificate of Workers'Compensation Insuronce,
P�a cer fied copy ihereof(Sec.3800,La C.) � � Cp�yNTy OF LOS ANGELES BUILDING AND SAFETI
c�N���70�—'a Com nn �
❑ Ceniiied copy is hareby iurnished. FOR APPLICANT TO Flll IN AODRE55 .3 t� �
❑ Cenifi d�yy is filed with tha co�nry building in BIIILDING b
ADDRESS
-�df�r�ant. /�� 1 .
�V� CITY 'y ZIP IOCAIITV
Dote�Applica Np.OF eLOGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF tAT� NOW ON LOT [RO55 ST.
COMPENSATION iNSURANCE aS5E550R
(This sedion need not be complvted if fhe pBrrr�it is for one 7RACf - BLOCK LO7 NO. Mqp BOpK PAGE PARCEL
h�ndred do{{aro(5�00)w less.) G USE ZONE �+P
owwE /l—3 3
w
t certify�hnt in the performance of the wwk for which this �� SPEGAL a
permit is issued,I shall no�employ any erson in any ma er A�DRE � C.r� CONDITIONS �
w as to 6ecome aubject to.the Wo r r' n s. l�l�(
GSY ZIP IJVL V
qafe JIt r Applicont ARCHITECT OR �l. DlSTRICf GROUP 7YPE FIRE PROCESSED BY �
ENGINEER NO CONST. ZON
NOfICE TO APPIICANT: �f, after making rhis Certifimte of /`, (��( �j
Exemption, you shauld become subject� to the Workers' pDDRE55 � � 1V l� �l' � y a
Compenwtion provisions of the labnr Cade,you must forth- TE�, SiniISTtCAI CWSSiF�Ca7iOtJ APT. � NDO• �
wifh [omply wifM such provlsiOns or Ihis permit shcll be �pNTRACTOR �71.+` � ���� �
deemed revoked. ��� , �A55 NO. DWELL.UNITS
LICENSED CONTR4GTOR5 DEC(ARATION r,p `�j�. (�
1 here6y affirm that l am licnnsad u[ule�prorisionc oE Ghapter 9 A S SEWER MAP
(commencing with Section 7000)of Division 3 of the Busineu �In, ,� `C . CtA55 VAUpllT10N .
and Professionx Code,ard my licerue is in full fwce o�+d effect. BK. PG.
� A� �1 SQ. / NO.OF NO.OF `CHEGC -. �-8�'�
License Num�e�'r✓���`� lic.Class ��� SIZE / STORIES FAMILIES ONE ;
ff VALUATIQN r c :.�. .�
t�k v�t �Date� �uRIPfION OF WORK MEW s li n �� _
Contracm,___ �'� �SP�- aoo Q JaC � I „ : �', .
❑(am exempt under Sec. �y2"�� ALTER ❑ � - .
B.A.P.C.ior Ihis reoson REPAIR❑ s v , ,
USE OF :�i.v � �. '
a,e�� ��5T��8��. �,�a
Signatur �`k� A�IP Nir t. ( . FINAL�r _
O fNER-BUI�DERDEGARATION � n� ��Q,�r DATE w����
I hereby affirm�hot I am exempt{rom ihe Contracta�s license qpoRE55"L (V'v� (�� �
law for the following reason i5eciion 7031.5,Bus�ness and F�� �
Professions Cade): PRESEN Br
BUILDING
❑ i, as owner of 1he propeAy, or my employees with qpp�u
wages m fheir wle compensation,will do the wak ond ����ry ,
the stwctare is not intended or offered for sale(Section
7p44,Business and Prafessions Code.) M���� ��'
❑ I,as owner of the property,am exclusively contracting
CONTRACTOR NO. �.C'� �.2 It
with licensed conrmctws b tanstrutt ihe project(Sea qoorzE55 �t�+ • • +�
tiOn 7044,Business and WofBsaions Code.)
REQUIRED yA� H�. OTAL SET&4CK FROM � FXIST.
LONSTRUCTION IENDING AGENCY Sei an PROP.UNE I •[� :.C U
I hereby affirm that ihere is a tonsiruttian lending agency for FRONT
the performance of ihe work for which this permi�is issued P��� ! •[� '�.:,. _,
(SeC.3097,Civ.C.). SIDE
P.i. U 4.1 1 -z c
Lender's Name �/
� P.G Fee S / '02 �„p�.. ��Ref.tl
Permit Fee ,
lsnder's Addrau
� I certify that I have reod this application and state that the Issuance Fee l d'� LDMA P/C k
� above informofion iscorract.I agree to comply with all County In�esrgation Fee �/"q
ordinances an State!a relo g to building construction, To+nl Fee '^� J•�� I�MA Perm.q
� and herebyC�'j�yylf�� se ives of this Couny fo enter
upon the �Ffi�fit' p rty for Inspedion p/��s,
I/ �L,.'
h f T fEE ItEVERSF FOR E%►IANATORY LANGUAGE
ignature of Applicpnt or Agent �a1e
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