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HomeMy WebLinkAbout1370 VALLEY VISTA (9) � WORKERS'COMPENSATION DECLARATION d�-+��! """'"'�� I hereby affirm that I hare a certificote of cansenl fo se�f APPLlCAT14N FQR BUILDING PERMIT � insure,or a cerfificate of Workers'Compensation Insurance, �,�rqfied copy theraof(Sec.3800,L .C.) � r� � COUMY OF LOS ANGELES BUILDING AND SAFETY Palicy No./l7���Company "'�� ) • ❑ Certified copy is hereby furnished. - � FdR APP CANT FO FILL IN - � � DDRES,�S ��7G �l � v� ❑ Certifi�ed c y is filed with the county building i c- 8������' 3'ro /1 M ADORE55 !,� ,sr�Y��'' fo—�—�%' Date `�Applim cITV + ziv IOCALIN NO.OF BLDCS. NEAREST CERTIFICATE pF b(EMPTION FROM WORKERS' � 5¢e OF LOT NOW ON kAT CROSS 5T. COMPENSATION INSURANCE ASSESSOR (This section nead nol be complefed if Fhe permit fs for one TRAR BLOCK LOi NO. M,qp BppK � pqGE PARCEL hundred doflars{$l00)a iess.) � � � owr.� 0 7 use zon� � J/!-33 3 I certify that in the performance of the work fnr which this j� ���� petmit is is5ued,I Shall nOt employ any person in any manner ApDRE55 V ��� C'pryDITIONS a so os to become su6ject to ihe Wor mp nsat n Laws. ` � � ��n � z�P t7U� � �ate �-� •ppplita � � � ARCHITECT OR TEL o-' NOTICE TO APPf.ICANT: If, aher makrng thia Cartificnte of ENGINEER � N� DISTRICf GROUP TYPE FIRE PRO�SSEp BY � fxemption, you ahould berome wbject to fhe Woricers y��i CON57. 20NE F- Compensorion provisions of rhe labor Code,you musr forth- nDORe55 f Vl �u ,�..Z T�VI � a with comply with such previsions or fhic p�rmit ahall be 1�. TFL w STATISTICAL C1A551FiCATION qPT, C deemed revoked. corrcas.croR W� ' No -(o`�j4��? ' Z LIG€NSED fONFR,4CTpR5 DECLARATfON qp -S . �� y�..,�a• �Uu NO.��WEIt.UNITS I hereby affirm that 1 am licensed under provisions of Chapter 9 � {commancing with Sectian 700p)of piyision 3 of iha 6usiness (� «<� �R�P and Professions Code,a�d my ficanse is in ful!fwce ond effect. �� �`^� �` �� BK. pG. VAIIDATION �{�� ��.1 5(].FT. NO.OF NO.OF CHECK License Nombe��ty 7� Lic.Class�_ Si2E Q STORIES PAMILIES ONE yALUATION ,.��S-� -:' Conhatto� `�"��1�')�Dofe-�q' � ����ONOF WORK NEW '� ❑I am exempt under Sec �^�LL A� ❑ O � � � � � • '_� nITER Q - � � . e C/: r B.BP.C,for this reason " �Pa�R❑ s _ � Dat� �� . s � . .. �� EXISTING DEMOI❑ 't .. Sc�o�r�,r� , ' ( l(h.� APPLICANT �� FINAL G c�I- O -BUILDER DECLARAiION �PRMT) i, . � � �hereby aHirm that!am exempt from the Contmcror's License ',��y� � -� ^'� DATE �/�r} �� ADDRESS �/�1�1' 1 V Law for fhe following reason(Sedion 7037.5, B�siness and FINAL� Professions Code): PRE5EN7 By BUIIDING 1, as owner of the property, or my employees with qpD�u wagas as iheir sole�ompensafion,wiil do ihe work and � the strucwre is not in�ended or offered for wle(Section ����r 7Q44,Busineu ond Professions Code.� MOVING TEL ❑ I,as owner of the properry,am exclusively contracring �MRACTOR r.�p' with 4icensed conhac�ors to conslrucf fhe projecl(Sec- qDDRE55 fion 7044,Business and Profassions Code.) CONSTRUCTION LENDING AGENCY gQgq� vs� Hy�y TOT PRETBACKEFCOM F7nST. ' �6 1 v.y F,. �hereby affirm that Ihere ia a construction lending agency for FRONT the pehormance of the work for wMich this permit�is issued P.L. ij.�. . + . j (Sec.3097,Civ.C.�. SIDE v.t. � r•�c,r"� Lenders Nnme /� ` / �! �ohW Ref.M S: , - - m P.0 Fee b T�O� Permit Fee 1p��'S g y e i-��-� ��- � lender's Addreu ^ I certify ihat I have reod this application and srate that the Iss�ance Fee ��"�U LDMA PiC N � ��1 � -��"' � above informafion is correct.1 agree fo compiy wifh ali Coumy In�esfiqaiion fae ryG�7 S ordinances ond Sfate bws relating to building tonstruction, Towl Fee 6 LDMA Perm M Q and hereby th 'e represent ives of this County to enter � � upon t v N'j�`n��/pr rty for inspection purposes. � L!�/ -�"'�Q SFi REVERSE FOR EXPUNA70RY UNGUAGE 'gnature of ApplicoN w Agent Dote w �. y G ✓ . .C� Q Q_`� wQ- 'C���Q �U��O c7 U, ' .O�'yro:E'pi c�_ �r,�+Y^ cU.4 c5• �, - �'�dg� or'�N U a�'c O'�a i t7 m 3.L�Vi fC` �! 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