Loading...
HomeMy WebLinkAbout1370 VALLEY VISTA DR (11) . I _______—_ � WORKERS'COMPENSATION DEGIARATION . - ' '� `' �3 t� .�.�y► i hefeby affi�m that 1 have a cestifimte of�����,o��f � _ APPL1CATION FOR BUILDfNG PERMIT � insure,or a certificate of Wo�kers Compensation Ins�rance, , 'or a certified copy�hereof(Set.3800,lab.C) COUNTY OF LOS ANGELES BUiIDING AND SAFETY '�ir.!-i{1•:� ? ' �i.aT�r. -,�+� � - Po�ity No�� C�irhpany- �:���i- -- 9UILflING J , ' ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AD�RE55 .!,,: J( ❑ Certified copy is filed with�ihe c nfy 6uil ing i,ispec- BUILDING r�-; � �f"'�,, tion department. f ��// I ADDRESS 1 I� f: ? ; i�r, f j:;.-i-r; �-r�i f �(/rit/ r%(t�-- citr �- ziP �ocnun Dafe�—Applicai5l�:e� NO.OFBL�GS. NEAkEST ' . CERTIFICATE OF EXEMPTION FROM WORKER5' SiZE Of loi NOw ON LOi CROSS 57. � � COMPENSATION INSURANCE qS5E55pR � (This section need not b6 Completed if fhe permit is 4or one TRACt `. BIOCK LOT NO. Mqp 6ppK PqGE PARCEL huodred dollors�3100)or less.) � TEt. � � O�NNER `,-.I_.. '..I- �,� Plp, -I i USE ZONE MAP /,. -x ;; a; Np, i � t certify fhat in tha perfo�mance o4 the work Eor whith this L./ ��{q� . permit is issued,I shall nof employ ony person in any.monner ADDRE55 !%` '�e•r f,�.. °� f�� �� ' f) CONDITIONS a so as to become-aubjee to ihe Worker'Carqggnpatfon Laws. , �� Q � � (' }/////i atr<'.�_ .r , r �;. zia U � Date ���'�I;�-J��-�-APPliconl�'`F•'� L�R/6V�.-1��.�, � ae �hao¢ / _ hi. w NOTICE TO APPIICANT: If, oher mokin this Certificote af ENGINEER / 3 p�p ,s::, r-s 9VSTRICf GROUP NPE PIRE PRG)CESSED BY . 9 CONST, ZO� �y Exemption, you should become sobject to the Worken' f f 7 /} � /'•.�� 1�i �����< r�.� } AD�RE55 �� l.r� n /��.4 I C•.L c.� • Compensation provisiona of the I.abor Code,yau musl forih- � . � wifh tomply with such proviaions or fhis permit sholl be f FEI. . '� S7A71571V,L CIASSIFICATION APT. CON00. Q � deemed revoked. CONTFtACTOR . e ' NO.:�- � - r�� Gt ��� M55 NO. �"�''1 DWEU.UNITS O IICENSED CONTRAC?ORS DECIARAiION r,�p a- ADDRE55 t here6y a4firm that t am liceased under povi�ibns of Choptw 9 � ��� SEWER MAP _ W " (commencing with Settion 700Q)of Division 3 of the Busineu CITY �C" -' .a �� VAUOAilO - ~ and Pmfessiona Code,and my license is in full force and effect. eK. PG. /� Sp.Ff. P NO.OF NO.OF CHECK � l'I[BnS�Nuritber "��•� ��-'�� L'1G CIasS � � SITE: ��� .p STOk1E5 = FAMILIES ONE . �� � VALUATtOH �Conhactor','� �-`� �•�`.�� ..� -'''Dafe '��r, DESCRIPTIONOF WORK �.E _r' N�' ❑ ry � �� � ADD 0 s !���/� .❑I am eaempt under Sec.--"`�}f r/� .r - " d AtTER ��,����� B.&P.C.fw this reason ../.� REPAIR ; ' , Da10: USE OF /, � DEMOL❑ N_o,t���.,�:L.wi . EXVSTfNG IDG. Signature A7FLICANi % . Y TEI. / FINAI �(`( �< '� '. �.,., +a:�J 4t Y: OWNER-BURAER DECLARATION (PRmTI , r / : / tvo..r,r.�.��z' DATE '';� � 7 » � I hereby affirm that I am ezempt from ihe Contractor's License qOD2e55 �'^`���-^'� �1c,. �(/� ••����J�� � law 4or 4he following reoson(Section 7031.5,Business and •��wa� ' ' ' Professions COde�: E EN s •� � �'�����'����� euaom�c „ � ❑ 1, os owner of ihe property, or my employees wiih p,ppR�,S _ � wagea as their sole wmpenwtion,will do the work and ����TM � � ! the strutture is'wt intended or offered for sale(Section a. � 7046.8usiness and Professions Code.} �v� TEL '�;�. GONTRACTOR NO. ,' .. � ❑ 1,asowwer of the property,pm exdusively contrpcting ,�p - with licensed contmcto�s to conshuct the prolecf(Sec- ADDRESS �'� - tion 7044,Business ond Professions Code.) � '"- :�i�{i,�.fi � REqUIRED TOTAL Ff&4IX FROM EXIST. � CONSTRUCTION LENDING AGENCY SE7 BA Y'4RD Hwv pROP.LINE wiorH . �� �'� � I hereby affirm that there is a mnstruciinn lending agency for PRONt r� �'"��'�'''''l�' the performance of ihe work for whith this permit is issu�d P��� �S� '�,'/�' (Sec.3097�Civ.C.). . SIDE � L.!�n F.S�CL.�� P.L Lender's Name � ��!'��',�,C;{"`.�'.1�:' $ � / —g LDMA Ref.M P.0 Fee$ "� Pe�mit Fee �� /. � , � Lender's Addrew �4�,����9 I certify ihot I have read this applicmion and state thal the issua�ce Fee ��% ��� �'� ��+�/+P/�M �g above infv�mW ion is mrrect.I agree to comply with ali County Investigotion fee :� wdinances and State laws r oting 10 6uilding construttion, io+ot Fae t' � � LDMA Perm.D � and hereby a thori rppre�ntatives of this Counry to enter u/p�on the � /��ropersy fw inspetlion porposes. 'g 1 ,� ��,,F„p,��.-ti �•�4-%� SEE REVENSE FOR EXPIANATORY LANGUAGE � �^ Sigrwtwo of Appliwm w Agenl Du+e _ . .. . . . ; - . . � � _ - � , ' . . ; , �x . , _- , • ' � , � �• � � : ���- - . - ; . . , . . - : : -. . : . � � , � � � . � , , - - � � � �. `, , • , . , � � .. _ . ' � ' �,,,,. ,, , . . . � . ' � . , . - f � , , ' . . . • ; . � • . . . _ � •` .. ;i i �' , � ' • � ; �;� � , ' � . . " � , � . ., , � '- 5. . . '�' . � 4, '. �. . .. Y �`. � � ,'�� 1 , , �'� � ' ' ' . . .1 � r . , �� �� � � • , y , , y ' ,� � + . ', �.. -��< < ', ' • " , � , ` . . . � � ,� . �w . . . . . . . �,:...y , . j' • _ . - �y`�� "�.+ " } 1 ' ' - . , ' . �� . . � f' . , . � • � - . � ' ' � ` . , i - , , ' . «� . ' . . • . . ' .. �'+� � � . . . S �s` . . . , ', . � r , `. ,p. , � � . �r. � .. . � � , �-'