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HomeMy WebLinkAbout1370 VALLEY VISTA (76) 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 .{ � � y beb�'im o . .-' cm o ac�c''m� »- ` ,.---'� w�d o � m m o c a t? ,.✓ �.,CI�O� O�.g. .T y,C... O d (�„ . C V11?"' 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