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HomeMy WebLinkAbout1370 VALLEY VISTA DR (7) I - WORKERY COMPENSATION DECLARATION �� � 'I hereby affirm rhat I have a ceriificate of tonsent to self qpp�ICATION FOR BUILDING PERMiT � insure,or a certificate of Workers'Compensation Insurance, or a certified topy the eof Sec.3800,Lab.C.j COUN7Y OF lOt ANGELES BWWING AND SAFETY �- �"0��-�3 N � olicy o. Company �'�T��Z�'� BUflDt�vc ❑ Cerrified copy is hereby furnished. FOR APPLICANT TO FILL IN qooaess �3'�� �(��� � T � Cersified co is filed wiTh the mun buifdin ina c- ����� .�a.� PY �Y 9 Pe ADDRE55 ,'�rLa �A`L�1 V 1S � Y �.L.P ttion department. �i—�— 'cs �.`�-iiS.a�`�To an � nv �acauTr Dafe AppiiCaM - NO.OF 8LDG5. �p�T CERTiFICATE OF E%EMPTVflN FROAA WORKERS' SiZE OF tOi �w���� Cn055 S7. COMPENSATION INSURANCE ASSESSOR (This cecfion need nol be complefed if ihe permit is fo�one TRAR BIOCK l0T t�. MpP 800K PAGE PARCEL hundred dollars(5100)or�ess.) TE�' USE Zonle 1✓aP OWNER� $ectC�l3eT�� 3 I ' 1 cerfify that in ihe performance of�he work for which�his 4� SpECIAI } permit is iss�ed,i shall nof empby any person in qny rtwnrrer ADDRESS Z si� ���1.� oo CANDITIONS p so as to betome subjett lo Ihe Wwken Compansolion Lows. u ciry wta►iaw•. G� zia��'�ato � Data App{icont ARCHITKT OR hL DISTRILT GROVP TYPE FIRE . PR�SSED BY Q NOTICE TO APPUCANT: If, aNer o+oking this.Cartificafe of ENGINEER NO. �p ZONE r Exemptlon, you should becoma au6ject �0 1F�e Wwkers 'Q A� � y� a Compensation prorisions of the Lnbor Cnde,you must forth- A�DRE � �V N with [ort�ply with wch provisions w ihis permil Shall 6e TE�� , STATISTIChi CLASSIFICATION APT. CON�O. Z deemad revoked. . ., CONTRACTOR � v'ta NO.� a --- - - � — li�, MSS NO.�DWF1L UNIT$ LICENSED CONTRAGTORS DECtARATION a�� �3 -�� gs� rio. 1'�1�:� I hereby affirm that I om licensed under provisions of Chapler 9 �t� ��� SEWER MAP (commencing with Section 7000)of Division 3 of the 8vs�ness Gtt 'a �.l�� ��u �—�� VALIDATfON and Profeuions Code,ond my license is infuN forw and offect. 9K. PG. r ...,��,,. 5q, p1p,pF Np.pF CHECK License Number���1`��' lic.,Class � �� � STORIES FAMILIES ONE YALUATION �ConfractorA��1i'��`,+�'t'�' Date`�3``$� DESCRIPTION OF WORK �`\�`r S NEN' � _ \ ���a f�](�j�Q A . . .. ._. .. _..... ,� , ADD IL'M � ❑I am exempf under Sec. ,b'� �'"31�` �� ❑ . � �'�i� � ��'� B.&P.C.far this repson REVAIR❑ s �•![5 Q Q USE OF ��e' EXIST�NG BIDG. �IX� �r A 2 Ca Q Q� Signarure A�jp�t)�y�� �•tiy-to --µp. q �jSoo FkiAL � ( OWNER-BUILDER DECLARATION DATE � �J D 5�0 9"H 9 I hereby affirm thol 1 am exempt from the ContraCfo/s License pDDRE55 3��� �+N���"� �� Law for the follow'rng reaaon(Section 703t.5, Business ond H�A�� Professions Code): ESENi gY ❑ I,as owner of the ro BUItDING p perty, or my employees with qpp�55 wagesastheirsolecompensotion,willdofheworkand ��iT, � the structure is not intended or offe�ed for wle(Section 7044,Business and Professiona Code.) MOYiNG �- iEl. _ ❑ 1,os owner of the property,am exclu:ively contrdcting �����R �� wtth licensed mMroctors ro construct the projact(Sec- AooReSs � lion 70d4,8usiness ond Profesaiona Code.} �7 1 3 b A REQUIRED TOTAt SETBAIX fROM � EXIST. . CONSTRUCTION LEN�ING AGENCY SE7 BA YaRo HWV pRpp,uNE W 1 here6y affirm that there is a mnstruciion lending agerxy far FRON7 #�r� � i} tha performance of the work for which this permit is iswed �P��� (sec.ao97,c��.c.}. s�� 2+r 3 b 7 5 RL . lender's Name p w �i LDM4 Ref.M r"'3�7 5" � P.0 Fee S �� Permit Fee L`�Z� Z tender's Address � �5.� �y�9 � 1 cartify fhaf I have read fhis applicafion and stafe that the Issuanca Fee �0 ��� LDMA P/C N $ ahuve iaformation is cArrect.1 agree to comply with all Caunty Invesiiga�ion Fee �b.�L+ ( R ordinances and State Iaws relating to building toastruction, ro+al Fee 7 IOMA Pe.m.N Q and h eby oyt e represen� �ves cf ihis CoaMy to enter . � � u he a� e- �y io r �rty for inspection purposes. - y � � yy ,f-� �S q,$'j SEE REYEYSE fOR EXRANATORY IANGUACE � ia Signoture of Applimn�or Agent On�e . . m _ oco�� � . • t rnv°E� a�o u°��j��..-�y Q , = y� cb�o.a.3�'���m'3wecse�� >.��°o:a � . � u,-��r�a, m a� o"'�r n$ 3 �a,,, U as,,csa a o...t- ai � ct $�,�o�� yCNg oy� o.v�.e��`03�� �, ",ya�,°��. ,d �, • - ��� Ey, �4.�"�',�'Q�n N >.3�;, ;.c • o m ��U� �� � � `` =v�ow •�a° �, cmwc.yP'� y'o,��o `°° � cmcc� O � , c.. _ = Q_C0.� oV-. sc �C � `:v�'cQ. 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