HomeMy WebLinkAbout1370 VALLEY VISTA (77) S�'R�iuo
/ , WORKERS'COMPENSATION DECLARATION � �
j 1 hereby affirm tFwt 1 heve a certifimte of�o����,a sa�� qpp��Cq,TION FOR BUILDING PERAl11T
( insure,or a cei�iiicate ot Worke�s'Compenwtion Insurance,
or a cer�i4ied copy thereof/(�Sec.3800,lab C.1 . COUNTY OF LOS ANGELES BUILDING AND 5AFETY
Oe�(�� 7b 'c�f^var,r /�'L� • aui�on�c
Ceriified copy�s hereby furnished. FOR APPt! ANT TO FILL IN qppREu '� �
❑ Certified copy is filed with Ihe county b�ilding inspea BUIIDING .�". �
tion depahnM�. / AODRE55
Dare i�'I��Applican�nr ��tit�''1 W(�rJ'fY�{�%hti5 C�tr Zir tocAury
T--� NO,OF BlDGS. NFAREST
CERT�OF EXEAAV7JON FROM WORKERS'� -� ����oT Npw ON ioi CRO55 Si.
COMPENSATION WSURANCE �E��
(711is Section need nof be Comp�eted if fhe permit ie fw One TRAR � K LOT NO. MAp 800K DAGE PARCEL
hund�od dollars($100)or Vass.) 7E
a ( ��«.� ,�P >/-3 33
I cer�ify that in the perfo�mance af ihe work for whkh ihis �W� ��
permit is issued,I shaH not employ ony person in any monner { O �,.� SPECIAi O
to W to 6ecome au6iect to thr Wwkw�CAmps�ation Lows. ��R COf�IT10N5
ry� U
cirr�. nv t.lJ a
Dule Applimnt ARCN{�ECT DISTR{CS GROUP TYPE f4Rf PROCFSSED BY O
(� 7TICE TO APPLICANT: If, after makin this Cerlifitala of
t .empfion, you should bawmo w6jacr to +ho Wakers' NGINEER � �� � + �� a
�Compensation provisions ot the lobor Cade,yau muat_forth- qDD
wifh comply wi�h such provi�ionx or Mie permit sholt be TE�. SiAiiSi�Cnt Cta55�FiCATfON � ro�• �
daemed�avaked. Coro�RnCTOR OR{Jt,�,{(�, i+�( No.�{J �1`[3 �fj z �
•
UCENSED CONTRACTORS DECLARATION G c_ p�, IXA55 NO.�owEtc.UwttS ��,
1 hereby affum ehat 1 am lice��d urder prorivan of Chopter 9 nU�RE55 0«S.X��$� W P• rw. DO ......
(commendng wilh Set�ion 700D)of Division 3 of ihe 9us�ne�s o�d UC. Q _.. ��R� - --. . . .. �
. ofessions Code,and my license is in full force ond effect. CtTv h BU U CL455 �+� ,_ .�,__ ..p�__... VALIDATION !
A2R $CI.FT NO.OF CHECK � I
� `T;J57� �it.C�OSf. .." $IZE STORIES �
licanse Numbar VM AS10�! �
1�b�'LF'lWL5��9 (0 p oescRiarion�oF K NEw ; yr�
, Comractor � Date�� p,pp y �� � �
l �I am exempt undar$et. AITER � �1��1 F} �
B.&P.C.for this reason �pq�R ❑ S �• • • •��
� omo. ��icisT°nc e�oc. °E"VO1 i •2 3&�C C
� Slqnature APMICANT . �• PIHAI _.
va�NT o. T..,
OWNER-BUILDER DECIARAiION DATE _ Y.� e a�„�.:_(��_
I hereby offirm�hat I am azampr from tha Contractor's ticense �pR� -��� ����N �
Law for the foVlowiog.reaaon(Section 7031.5,$usineu and s fl�'��—��'
Professions Code): y
t � � BUILDING
i I, a:owner of the property, or my employaes with ADDRE55
wages as their sole compensotion,witl do the work and ��q��TY �
ihe shuctvre ia not infended or offe�ed for sale(Section
� 7041.B�cinest ond Profassions Code). MOVING iEl.
❑ CONTRACTOR ��
1,os owfrer o4 1he prop�wty,am ezclusively conlracting
� witb licensed conhocfors to construcf fha projecf(Sec- qDDRES$
tion 7Qd4.8usineu ond Profeuions Code�.
E�UIRED YARD HWY T A� �K
_ CONSTRUCTION tENDING AGENCY SET BACK PROY.LME w�orH
I here6y affirm ihal there ia a conatmction lending agency for FRONT
' rhe performance of ihe work for which this permit is issued P.i.
� ISec.3097,Civ.C.). SIDE a 2�/2�7�ri
P.l.
' lendai s Name #A� • • � �
r� IllMA Raf.M
` Lendei a AddfeK P.[.Fea 5 vermit Fee {�'� , � 6 C p��C
� I cerHty that I have read fhis appiication and stme�hqt the Inuanca Fw ��'� ���P/�k �r�(:��?;�:�
9 obov�informafion i�correct.I ogree to comply with oll Couny Inveulpatlon Fes �e��0 �
$ ordinoncrs and Statr law�relo�inq to 6uilding construction, ioral Fae 7 �DMA ve�m.M -
$ and heroby authorl=o raproi�nlotives of thit Counry ro enror ' �'C �—�?�
� upen�h■ 6ov�•m�nf1 s[c{J,properfY fa inspoclion purpoa+s.
s �, � ; �1 .�„� (�/$g fii�iViRii FOR F7RLANAiORY UNGtIAGf
sfyrwmr ct opc��wn�w Aw�r po�.
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