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HomeMy WebLinkAbout1370 VALLEY VISTA (11) � S�'R i uo WORKERS'COMPENSATION DECLARATION �-7 I hereby affirm tMt I have vi certificate of consen��o self APPLICATION FOR BUILDING PERAl11T insure,or a cei�iiicate ot Workers'Compenwtion Insurance, L� or�a)cer�i4ied copy thereof/�(Sec.380p,lob C.) . r� � COUNTY OF LOS ANGELES BUILDING AND SAFETY Poficy��� 7b �CbfriPo�r /� . � Ceriifed copy rs hereby furnisbed. FOR APPI! ANT TO FILL IN B11°'"� -,3 (� AOORE55 � Certified copy is filed with�he county building inspeo- BUa�iNG .4L, � tion depprhnmf. � � A�DRE55 '�1' Dare �___�-1,_��npplican��r ��brt/'1 w!��JrrL{�JhtiS nrr zir �p�.ury CERTIFICA7E�OF EXEMV7JON FROM W— ORKER� P/O.OF BlDGS. NFAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON t07 CRO55 ST. (7his section need not be completed if the permit is fw one ASSESSOR hundrad dollars($700)or lass.) TRAR L K LOT NO. /J�qp gppK DAGE PAR�L a TE use zor� n�ar / y I cenify thaf in the perfo�manca of ihe work for which this �W� � NO. �(�J.33 permit is issued,I shaH not employ ony person in any monner { O ��� SPECIAi � to w to 6ecome au6iect to thr Wwkwi Compenation Lows. ��RI ry� COt�IT10N5 0 ciTr f�. nv t.lJ V Du�e Applimnt ARCHITECT a (� 7TICE TO APPLICANT: If, aftx making this Cerlificala of DISTRICT GROUP TYPE fIRE PROCESSED BY O NGINEER l .empfion, you shouW bawmo w6jacr to tho Wakers' r COKS U �Compensation provisions oi the Labor Code,yau m�at forth- ADD r� � � W wifh comply wi�h such provi�ioni or Mie permit sholt be TE� p� deemad ravaked. CONTRACTOR OQ�,G/� �ft( NQ'� ,'.t7J SiATISTiCAL C1A5�51F1'C�AjTfON . CpNpp, (n G IXA55 NO.�_ z UCENSED CONTRACTORS DECLARATIQN p�, DWEkE.UNITS 1 hareby affirm ehat 1 am licensed undx prorisiom of Choptar 9 qppRE55 p��.SSpYlf�$C( �,�I►7• ryp. D� �'� (cOmmenting wilh Set�ion 700D)of Division 3 of iho 9usino�s ond ��" Sf WER MAP - " "-. . . .. ...... 'I ofessions Code,and my license is in full force ond effect. Ctiv h Bv,V �IC q55 I • �$ ---� - � . .�... ..y� _... . vALIDATIOH � ' _ i /� C S0.FT NO.OF CHECK � � li[anse Numbar -r�`��� �i�,Clpy{� SIZE STORIES p� iW��F�.�.t�.�5iri� Dare VAt wTlOi�► Comrac�or �.�+f9 (0 p oescRianohoF K NEw ; r �• i � � � J � �19Q1 f7 i � ❑I am exempt under$et. ��R � B.&P.C.for Ihis reoson &Epq�R � s �.'� � � �l`^, { �me: Eu7(gTNG BLDG. �'� � 1 •2 3&�G G � Slqnature APMI�.4NT . E. PINAL OWNER-BUILDER DECIARAiION FRINT �� DATE _ ,�s/ e.���:G(�� I hereby affirm�hat I am ozamp�from tha Contmcfor's License �y/� r^ ��Q n, - - law for the followi�g.reaaon(Section 7031.5,8usiness and ADDR�oS`a�G If�YW� �� 'v NAL Q�i,L�-b� t Professions Code): gy � � BUILDING iI, a:owner of ihe property, or my employaes with qppRE55 . woges as their sole compensotion,witl do the work and � fhe skuc��re ia not inlended or offered for sale(Section ����TY 7011,Bucineu ond Profassions Code). MOv�NG ieL. � I,a3 owner of Ihe property,am azclusively conlracfing CONTRACTOR NO. � witb licensed conhocfors to construcf fha projecf(Sec- qDDRESS tion 7Qd1,8usineu ond Profeuions Code). E�UIRED T pl BA K - CONSTRUCTION IENDING AGENCY sei BaCK YARD HWY PROY.LINE w�oTH I hereby affirm ihal ihere is a conatruction lending agency for FROM rhe performance of ihe work for which fhis permit is issued P.i. ISec.3097,Civ.C.)• SIDE a2929i: P.l. ' lendai s Name 2�� innaa R.r.x #,• • • • � � Lendei a Addrecs P.[.Fea S Vermi�Fee ' � 6���r C � I certity that I have read fhis appiication and stme�hqt the Inuanca F�� ��'� LDAAA p/C N 9 obow information i�correct I agroe to comply with all Couny Inveulpatlon Fes e •r�(:��?��•i $ ordinonc�s and Statr law�relo�ing to 6�ilding construction, ioral Fae �)��� �pMq pe�m.M V R and heroby authorl:o raproionlotivai of Thit County ro enror � �.C j_�;. � upen fh. 6ovs•mann� propsny for inapaclion purpoa�s. � � g l/ � ; .�j�� e s � �`- �'*�C.. i�$g fii�iViRii FOR F7RLANAiORY UNGYAGf Sigrwtur c4 Appliwnt w Ap�nt ppt� � ... . .. ' .�. . , . - ,� ,.�� � � xcze ..,� s. � v� �� � z�` oy `'..;5 � .r v �;,i�,�!� � fi,..n ' i, '4 y 3 0 o e � -� ` �in : � � ~ .x^ �-�c : s °.r a � ,_ � ;• ; o •%i c � a c � �,�._ �:. �, � o _ ^ �,y y: �r "^. �� e+ O �� f y +�w Q i V fU �' y\�, V , . . 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