HomeMy WebLinkAbout1370 VALLEY VISTA (28) WORKERS'COMPENSATI�N DECLARATION APPLICATIQN FOR PERMIT
I here6y affirm that 1 have o certificate af consent to self
insure,or a cenificote of Workers'Compensotion Insurance, ���� NEATING - VENTILATING - AIR CONDITIONING
ar a certified topy'thereaf(Sac.3800,La C.)
�— CE-81B(REV.10/81�
P❑olicy No.��J�pm��y v4—
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUIIDlNG AND SAFETY �
�Gertified copy is filed with the county building inspec- /
l FOR APPLICANT TO PILL IN BUILDING
ti n e r ment." �+O / ADDRE55 137v �
� I--1 �j�„� �PRINT OR TYPE ONLY)
Date� Applicant��t " ' IOCALITY
NO. �iTpE OF ME � FEE A,
GERTlFlCATE OF EXEMPTION FROM WORKERS' NEaaE57
COMPENSATION INSURANCE ' CROSS 5T.
(Thia�aclion nwd not bo eomplN�d if ffw yrurlc involwd 6y ABSOR �T, U� oisraicT rio. wocesseo er
1ho pormit is br ona hundrod dollon(37UOJ or less.) �� A(� ��
I certify ihat in the performance of the work for which ihis R N `v��
permit is issued,I shali not employ any person in any manner `
so as�b become s�bject�o ihe Workers'CDmpensation Laws. naceov�us DAiE INSPECTOR'S SIGtL�TURf
Date_,�pplitont -- . 4aMR�554g.@TU ° RWGH 'j �y �
NOTICE Tp AFPIICANT: If, aher mak'rng ihis Cer�ificare of VENTILATION SVSTEM ' Firui
Exemption, you sho�ld become svbjecf io the Workers' �
Compansation provieiona of the labor Code,you must for�h- EVAPORATIVE COOLER VALIDATION
with �omply with such provisions or this permit shall be �
deemed revoked. FURNACF: FAU_GRAVRY
LICENSED CONTRACTORS DECUIRATION FLOOR aTu
I hereby offirm thal i am licensed under provisians of Chopfer 9 HEAIER: SUSP€NDED UNIT_ ,
([ommencing wifh Sedfon 7pp0�of Oivision3•of 1he Busi�ess WALL �
nnd Professbns Code,and m Gcanse�s in fivtl fwcey�effect. � '
license N�mber—Y 74�4 Lic.Class C �� � Q �
rz� � � � 0 1 J Q `? i
Conlractor ppte � , � O �
❑ 1 am exempt�nder Sec U �
Plon check ee
B.&P.C.for this reoson � � ��m w �
PERMIT ISSUlNG FEE; ta �' �' "`�� N E
Date:
5gnature TOTAL FEE ' z �
OWNER-BUILDER DECIARATION PlAN CHECK APPIICANT
I hereby affirm that I am eMempt from ihe Controctor's License �
Law for ihe following reason(Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the propeity, or my employees wi�h A�RESS
woges as iheir sole compensation,will do the work and � � � 2 l� li J.'-
the atructure is no�intended or offered for sole(Seciion G7Y TEL NO. f y _ `�
7�44,8uciness and Professions Code). �� �'�'^l:
� OWNER ��A
I,as owner of Ihe property,am exdusively contracting �T
with licensed mnvacrors to cons�rvcr rhe p�ojec�(Seo- '��� �,/J' ' '
tion 7044,Business and Vrofessions Code). ADORE55 v cc���fff,""
�ONSTRUCTION LENDING AGENCY air � � iE�.Np. �C�a�
I hereby affirm tha��here is o construction lending agency for
Ihe performante of Ihe work for which this permit is issued CONTRACTOR �� � � �
(Sec.3097,Civ.C.�. �e��Q�.��
ADORESS -
n -.
Lender's Name • 2�,�(y� �:
GTV �v TEL.NO. 9q�^L� Q
Lender's Address �'� 4_k;� �
1 cerlif that 1 hove reod thfs a limtion and slate thot the STATE /� ���' �.—^� t �
Y PP LICENSE NO. Q V CLA55 G-D
above infor ation is rorrect.I agree to comply with all County �
ordin s and Staie laws relating to building construction, (��
ereby iesentatives of this County to enter ��v
ove- _ ped property fof i�e�ii purposes. SEE REVERSF FOR EXPLANATORY LAMGUAGE
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