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 . .
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