HomeMy WebLinkAbout1370 VALLEY VISTA (10) WORKER$'COMPENSATION DEQARATION �
I hereby affirm thot I have p certificate of consent to self APPLICATION FOR �UILDfNG PERMIT ��
insure,or a certificate of Workers'Compenwiion Insurance,
or cerrfied copy thereof(Sec..380D,L .C.) � CpuNTY QP LOS ANGElES BINI�{NG AN�SAFETY
�j'y�.��/� Pa Y � .
Po ic o. Com n BUILDING '1 /�'
❑ Certified copy is hereby furnished. FOR APPLICANT TQ FiLL fN AWRESS ��v (/ v� ^'''
❑ Certified copy is filed with iha c ilding ins - BWlo�nrG 2)O A I I �V \t{CT� /(
. tion dapartment. ADott�SS -J � t"titi�V{�,�5, V Ec�t __�
/� `'(� CITV lYwf�{,J �P LOCALitt
Date�App4iw NO,OF Bl�GS. NEAREST
CERTIFICATE OF EXEMPf FROM WORKERS' S11E OF LOT NOW ON l0T CRO55 5T.
� COMVENSATI INSUR.4NCE � q55ES50a
(This sedion need not ba completed i#the permit is for one TRAR BLOCK LOT NO. AAP.p BOOK - PAGE PARCEL
hundred doflarc(5100)ordeu.) N,qp
. OWNER G USEZONE NO. � ��3 3
�certify thae in the performance of 1he wor�for wh;ch this � /p �r A' svEcra[ - � a
permit is issued,I shail nut employ any person In ony mannar ADDRE55 � - � ��a• t„i+"1 COn1DfTIONS �
w as to become wbt�t�o�he Workers'CompBn�ption Laws. �OJ�(�) � (�
CI7Y ZIP lJ! I
Date Hpplimni ARCHI7EQ OR � TEL _I 1 + OISTR GROUP NPE ZON pROCESSE�BY p
NOTICE TO APPLICANT; if, afler makinp thii Certifiwte of ���R � � � � CONS. U
Exemptio�, you should become subjecr to the Wakers /}?� N1 �. !(} �J Z �j � � a
Compenwtion p�ovisions of�he Lobor Code,you mosl forih- ADoaeSS'b L N
TEL. STATtSTICAt CIASSIFICATION APT. CON .
with comply with such provisions or this permit ahall 6e .. Z
deemed revoked. . . CONitiACTOR ' �� � �j —
LlCENSED CONiRAC[ORS DECLARATIQN IIC. CtA55 NO. ..�WELL.UNITS
7.S- 5'0 S-r r�. 6-?ofJ
1 hereby aHi�m that I am 4icensed under provisions o#Ct�apter 9 A ��� SEWER MAV �S'
(commencing with Sedion 7000)of Division 3 of the 8osiness CITV 4 ��� � � V�fON.ri
and Professions Code,and my Ilcense ia in full farce ond effect. 9K. PG.
-7 SC]. NO.OF NO.OF CHECK
`�a� Lic.Cloas � � • SIZE ��� STORIES FAMIUES ONE YAlUAT10N i� • r o �.:-'
. License Number�s� �"
Con1fO[t0 L`��1 �^'Dele ����, DESCRIPTION OF WOftK NEW : q "�1 � � � 1 . . � ,
�r � ,� r,. .,
"`�I om exempl undef SeC. q��q ❑ •" � �� � -
� B.&P.C.far ihis reason RFPAlR❑ s ;,'i(��-'�.�
USE OF . _ _. .���� - .
� EX45T4NG BIDG.
� Signo re �PR�T FlNAt x
�E-B llDER DECIARATION l 1 � � UATE � � a,
I hereby affirm that I am exempt from�he Contrador's License qDDRESS 2 U N I V�25i1Y p�MA�+ �
Law for the followiog reasoo{Section 7031.5, Business and ��
Professions Codej: � P ESeNT ey (�v'
❑ I, os owner of the property, or my empfoyees wiYh qpp�55
wages as their sola compensation,will do the work and �«A��n,
the structure is not intended or offered for wle(Section - -• •
7044,Business and Professions Code.) JJd7V1NG TE� �C..������r-•.
CQNTRACTOR N��
❑ I,as owner of tha property,art ezcl�si�ely contracting . . a .
with licensed co�fraciots to Construct fhe projecf(Sec- ADDRESS �y •
fion 70d4,Business and Professions Code.)
RE IREO TOTAL SETBACI(fROM � F7(�ST.' I ' � �4 ��J
CONSTRUCTION LENDING AGENCY SEf BACK YARD HWY pR P LIN WI
I hereby affirm thot there is a construction lending agency for FRQNT _ _ . , �.
the performance of the wo�k for which this permit is issued -P��� ��1 ! r � "��
(Sec.3097,Civ.C.), sioe _, ,
v.�: G '• .
lende/s Name /
S �2 , //�•�r IANA Rei.N
V.C.Fee a.� �� Permir Fee (O J
� lender's Address e�-�
(certify fhaf I hava read fhis applicafion ond slate that the Issuance Fee �� "�� LDhw P/C N ►
� a6ove information is correct.I agree to comply with pll County Investigmion fee J/
ordinances and State laws relmin to building construction, Totol Pea � '�""�'S LDmn ve.m 8
and here6y ut or' r r n�at� s of thia County to enter , .. .._
� upon t o i o far Inspection purposes. ' �
� r�C� SFE RENEItSF FOR @XPIANATONY UNGUAGF
Siqnature af ApplicoM or Agenf Dale
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