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HomeMy WebLinkAbout1370 VALLEY VISTA (45) R� � , �� 7, �� WORKERS'COMPENSATION DECIARATION ' � , � / q� I here6y affirm tha�I have a certificate of consent to self APPLICATIQN FOR BUILDING PERMIT � 'insure,or a cer�ificate of Worken'Gompensation InsuraR�e, � or a certified copy�hereof(Sec 3800;lab.C.) �} COUNTY OP LOS ANGELES 6UILDING AND SAFETY � Policy NO� Compqny..•=:�••• ,.4 • :Vt��''1�_': t:,: " - ❑ t�itt��md�i��}ie�'eby 1�umished. � FOR APPLICANT TO FILL IN suaoir� F ! AODRESS ��; (;� . . � ❑ Cenified copy is fiFed with the coun.ty building inspec- BUiIDwG �^•�'r ��. . �i ��•, .. fion d�parfinent. ,� AD�RE55 kf �� �.: , �..� �- i� f,� " l � ;f' ` � L � . Dat � r'f Applic�W-� ".! . 1::�,�. CITV�.iirl��t{7�,�,'/� �'�~�i�' zIP LOCAtIiY NO.OF BlDCS. NEAREST CERT{FICATE OF FXEMPTION FROM WORKERS' SIZE OF tOT - � NOW ON lOT CRp$„c ST COMPENSATION INSURANCE ASSESSOR (This secfio�nesd rro�be completed rf the permit is far one 1RAC7 BLOCK LOT NO. MAP BOOK PAGE PARCEL . hundred dbllors($100)or less.) i ,.� i , OWNER '.t i'-(.',4 i :�';i,... . 'INO.. t.�F.'1.i .�ri 1t5� NE MAP - I certify ihat in ihe performance of fhe work for which Ihis -I - s NO. �" - . permif is issued,I shall not employ ony person in pny manner PD�RE55'�{�� ��i;;, � � SPECIAL l �� �" •7 CONDITIONS so as ro become su6ject to the Workers'Compensation Laws. � � � - ' CITY �.i�`. ZIP �"�i.):.:t Ar a Dqfe Applimnf ARCHItECT OR� � , i -°,� .. � S#L '`�� DISTRICf GROUP 7VPE FIRE PROCESSE�8Y O _ NOTICE TO APPIICANT: If, aNer making this Certificate of ENGINEER �; .:p�p. . &emption, you should 6emme subiact to the Workers' ;;�}� _ /rM CONST. ZO�Ie j � Compensafion prorisions af the La6or Code,you must forth- AADRE55 % �' ( f':. ; ' N � �t��� � , u. wi�h comply wirh such provisions or �his perm�� shall be �� rE�. y STATISTICAL CtASSIFICA710N AP7. CON ` } deemed revoked. corarnncroR� . _No.r; �lY�3� oc LICFNSED CON7R4CiOR5 DECLARATION - uC. - �y Ctq55 NO. �%'�'-� Owell.UNITS � I her9by offirm thaf 1 am licensed under provisions of Chapfer 4 j0'��� .� `j" ` � ���^^" ``�'�� g r 4.:: � �. UC SEWER MAP �.(commencing with Setlion 7000)vf Division 3 ot the Business ���„ } �;t,,. , _ `� �� ��� � � and Rofassions Code,and my license is in ful{force and effect. - ° � �` VALIDATION ;�L(,�,�„�f��). %, � �EFf'�ir`�i,1, STORI�ES :� FAMIL�IES Y ONEK BK. PG. � Litense Number � Lia Class U ti F .. AA YAL�)ATION CoMracto/- ��� �"-: 'pate } �'j DESCRIPTION OF WORK NFW ❑ s w:.t �:,i��� y � , �. ❑i am ezempt under Sec. 9�-�` �i `iu:.� :i�. ADD ❑❑ ..�`.4.S.F'�, � B.&P.C.for this reawn ;-` Al7ER . - '. . - REPAIR❑ s !;.��.�i�;�C i te�'',,,�� FJ(ISTNG BLDG. . .:. DEMOL❑ �. . � //r`� � ' ��.�.�'�;'Y,i.��' Signoture; '�' ,{�/• �'iL�-�i.lei APPLICANT�.:. . : . -�rEi. � _ -. � . Z (PRINT) f > 1 1�.� .•.I.'j;..r�il� NO. .��i� �.i•-� FINAL '�"� �� OWN�R-BUILDER DECLARAT40N "' pA� , ,;.i.�Y.��, I hereby affirm that I am exempt from the Conirano(s License -�'_y�� : ;'J � Law for the following reason(Section 7031.5, Business and A�DRE55-�-"��' � • ' ' '�- ' F�NA� „��'�.G-��f Profesaions Code): PRESENT By ❑ I, as owner of the ro ert or m em lo ees with BUILDING ' '� P P Y� Y P Y ADDRESS '. wages as their sole compensation,will do the work pnd � � the structure is not intended or offered for wle(Seclion ����Tr � 7044,Business and Rofeuions Code.) MOYING iEl.' � . ❑ 1,as awner of the property,am exclusively contracting CONTRACiOR Np. + � with licensed roMmctors to consfruct the project(Sec- ADDRESS � � tion 7044,Business and Professions Code.) �� �_� EQUIRE� 70TA1 SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY �gp�K YARD HWY pR P.LINE WI TH '` 1 hereby affirm that Ihere is a construction lending agenty for FRONT � � the performance of rhe work for which this permit is iuued P.t. % �:.r K''.%'fc Sat.3097,Civ.C.. SIDE _ � �� , . .. � l 1 P.�. �r+,�f!` t�..�. �nders Name ' � � � ,` to �i�!�.�,.f.IiM c.� P.C.Fee S �-I f+ �� Permit Pee 8 'w's Address . , .�:.�:.�,r��,' �. L�+.L: •that 1 hove read this application pnd state fhdf fhe Issuance Fee � � C q , �. 'ormation is mrrect I agre9 fo wmply with all County Irnestigation Fae ` ti '- y�F��.�y C� and State laws relotyiq�to 6uilding con¢trudian, Total Fee 1 � \�� � toMA Pe�m q 5ujho'xe r�p sempt�ves of this Co�nty to enier b-�ient' d q rty fo�inspection purposes., - '��'+�.. ��';1�"`�f� SEE REVENSE FOR E%PIANATORY IANGUAGE ' ; �ppiicanr or Agent Do�a I ` � �a� `� �° �ec����'.�`e5 . .t � � �a,a av��g<Bey o - . � .�'o� . oaca�,�r, g o4 r. . , . ' . �`.4��• JPO � o,�ut . . . ' .- . � ' . . . ' . . 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