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
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