HomeMy WebLinkAbout1370 VALLEY VISTA DR (2) � WORKERS'COMPENSATION DECLARATION �
I hereby affirm,�,,��e o�e,,;,;�a,B o,consent to self APPLICATION FOR BUILDING PERMIT
�nsure,or a tertificate of Workers'Compensation Insurance,
or�ertifOed cOo y thareof(Sec.3800,Lab.C.)
� 6 �3(,4 �Q� �,Q COUPITY OF LOS ANGELES BUfLDING AND SAFETY
Policy o. Company ��7��
Certified co is hereb fyrnished. BUILDING �
PY Y �¢� FOR APPIICANT TO FILL IN ADDRE55 :�
KA Cerlified capy is filed with tha wunry building impec- BUIIDING / �'}
yCJ ��on.depa ant. ADDRE55 /� /Q VA�Y ISTA DR �p(q��Ty
DateQCY� � A litpn ��Ty �A�J� ►]f'!R NE4RE5T
PP ziP � cao55 si.
CER7IFICA7E OF EXEMPTION FRO ORKERS' NO.OF BLDGS. qS5E55pR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PAR�L
(This sedion need noi 6e completed if the parmit is for one T�tt BLOCK �OT NO.CJ� 1 USE 20NE M,4P � ` �
hund�ed dnllors(S10Dj or lau.) ni0.
I ceni rha��n rhe OWNER roR Es r'�,o. y� 1"1� ���A�
r
�y parformance of the wwk for which this CONDITIONS eL
permit i3 i66�ad,I shall not employ any pe�son in any manner A DISTRICf GROUP TYFE FIRE PROCFSSED BY �
so os to 6ecOme Subjact to Yha Wor s'Com enwtion Lpwa. ADDRE55 (� �I1�lLS1�1/C�v pl.yO, �` CONSt � ZONE U
�JOo�'7. � �
Dat T �� APPlicanf CITY L�S ZIP APT. CO . �
-`�OTICF TO A ICqNT: If,�oher moki his Cerl"rfimre of ARCHITEROR ��,'7�� $7ATISTICAlCLA551FICA
� ENGINEER 1LL Np, �� U
npfion, you chould betome subject to �he Wwkeri CLA55 NO. OWEu.tl�wi5_ �u
ipanso�ion provisiona of the labor Code,yo�musl forih- ppp�� jb815 v N ART JE, of SEWER n�wP �
with comply with such proviaions or this permit shall be �N Z
deemad revoked. � tEL. • �
COrvlanCiat -p NO. eK. rG, VALIDATION
LICENSE�CONTRACTORS DECLARATION ���.16�''�Z
1 hereby affirm tlwt I am licensed under proviaiona of Chapter 9 ADDRESS 3 T NO. VAlUA710N
(commencirg wilh Section 7000)of Division 3 of rha Business and uC. /
Profescions Codo,ord my license ia in fufl force ond affect. Citv � • CLASS�b. E ''2� S�p
!Gn—g2 �.�. �.� /� Na.� .. _�E�
licanss Num6er �;�,el�u C��_ size sroaies G fAMIUES oHe z 2 4 t�0 A
Canirnclor�LLHe.) IyV'l�V . pp�a . T 'R , DESCRIPTION OF WORK 7L�L� NEW � S � '�3 �
• • � •
❑I am exampt under Sac. • —C�IRTIC � � �N Aoo � �
K ALTER � FINAL � •�O 5,7 8
6.8P.C.for this reawn s 'T—�n'+ V REPAiR � �ATE /���c��� � a �7 r,s
U�� ,` G:]
Dote: EXISTING BLDG. p�„�pL � FINAL �s 1-
Signatufe APPlIG4NT TEL. Br I u 4' /"�7
OWNER-BUILDER DECIARATION ��NT TI NO. Oa
1 hereby offirm thae!am exempf from the Controctor's License p �
Law for ths folkowing reoson(Saction 7031.5, Businesa ond ADoaE55 3 � T(��A,ti$E S j . U�[(�.
Profession3 Code): pR -
� 1, as owner of fhe o BIIILDING
pr perry, or my employeee with ,4��RE55
� wogas as their�ole tompanaation,will do 1ha work and
the structure Is not Intended w offered for wle{Sestion ���m'
7044,Businass and Professione Code�. MOviNG te�.
� �,as owner of the property,cm ezclusively cOntra[ting NTRACfOR NO.
with licansed conimdors to constrocf ehe project(Sec- Ao�E� •.�3 Z 5,3 A
tion 7044,Businass and Rofessions Code).
REQUIRED TOTAL SETBACK FROM EXIST. ?fi� ��� � �
CDNSTRUCTION LENDING AGENCY gT�� YARD HWV pRpp ��NE WIDTH �
I hereby offirm that there is o construclion lending agency for FROtd7 � •�c 8 2.O O
fhe performance of�ha work for whieh Il�is permit is issued p.�.
tSec.3097,Civ.C.). SIPE � � s %.�.C.r�t�cYi
P.L. `
W Lender's Name ' .���`8,7
� lender'a Address P.C.fee S 4 O S �8 Permit Fee � / .Sv
�
1 cartify Ihm I have read thi�appliwtion and smre that ibe Issuance Fee �V'�v
� above information is cwract.I agree to comply with all Co�nry �����9a��on Fea p�Q O
ordirwnces and Stme laws relaling to building construction, Toial Fee ��
lY ond hereby aulhorize represenwtivea of fhis Co�nty to entar
� u a obo�-ment�ropany for Inspecti��
� SEE kfVFYSf FOp E7(PLAHATORY LAMGUAGE
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