HomeMy WebLinkAbout1370 VALLEY VISTA DR (12) � WORKERS'COMPENSATION DECLARAT�ON ' ^
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`' 1 hereby offirm �hat I have a cer�ifica�e of consent to self qpp��CATIOIV FOR �UILDING PERMIT v
insure,or o certificote of Workers'Compensation Ins�ronce,
r a certified cop thereof(Sec 3800,t L'b.C.)
F`''`' ` �c.%�' ��+E±`_t r`:�a. WUNTY OF LOS ANGELES BUILDING AND SAFETY
,,� s ::�. ;�; ��1,
61i�cyNo� Company �
Cerlified co is hereb furnished. BUII�ING �`�.1 t l..��r F � i
- P�y Y fOR AP LICANT TO FILL IN A��� yj � �3 1��. ��t� . i ��"
� Certified mpy is filed with the C(}unty building inspec- BUILDING t - y �
�ion de artment. t ��:� �i!f y�i_� rl
j P �i _�� ADORE55 I f I f�. 'i �J,';..,
�o�eJl•I• ! ) APPlimni �:�I�e,,fi-7Jil-��1.�'.-f arr`-��M +:i..:�r.l ;;�?,rr4 ziv �ocnurr
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. NFAREST
COMPENSATION INSURANCE S�zE OF LOT NOw ON LOT CRO55 57.
�This section need not be completed if the permit is for one ASSESSOR
hundred dollors($100)or less.� T�� r g��K LOT NO. /�qp gppK PAGE PARCEI
OWNEa`-� �`-'�Ye•�•�I r.'.i.":,e� N�' ,j' r� USE ZONE NY1P �
i certify thu�in ihe performance of ihe work for which ihis ryp, d
permit is issued,I sholl not emplay any person in any monner SVECIAI V
so as to become su6�eci to ihe Workers'Compensation Laws. ADDRE55�' ' +�_� � CONDITIONS
_ ..W.1
CITY ?%''r'��f°- _ -� i.ZIP �'` -= -'l:z
�ale Applicant . LL
NOTICE TO APPLICANT: If, afte�mokinq this Certificofe of ARCHITECf OR TEL. pISiRICT GROUP TYPE FIRE DftOCES5E0 BY
ExOm fion, � ENGINEER p�p_ �
p you should become sub'ett to thg Workers' CONSir^""� ZONE p�
Compensofion provisions of}he Lo6or Code,you must forfh- - J�•� L. a
with mm 1 with such rovisions or this ADDRESS . . � . �
PY P permit shall be ,}�� ,) / � �-�-" \��\`��� � �
deemed revoked. CONTRACTOK�^"+�t:'1V 1�'� ° r ��f-��� I I STATISTICAL CLASSIFICATION AP7. CON�O. 0
�%cj `��';vMO.�t��,'-�;+'> fi.
LICENSED CONTRACTORS DECLARATION , ��� QA55 NO. " - DriEll.UNITS_ �E
I here6y aflirm thm 1 am licensed under provisions of Ghapter 9 ADDrsE55�'�=� t!�'.� -iL+.�::?:i. ".�NO�E•,<]'�'�.�., F
(commencing wilh Section 700p)of Division 3 of the 8usiness and .- •3 ', � ��� __ t SEWER MRP
Professions Code,ond my license is in full force and effed. CITY'%''- < ti../`G s CLA55�`+' 1'-' VALIDATION
SQ. NO.OF NO.OF CHKK BK. PG.
r � i� r
Li[enSeNurr`ber ''��{ � ' � Lit.Class �" ��`�'� 512E��-'-� STORIES FAMILIES ONE
� ! VALU�jION
��FLt,'�,•�f•���1-•� � • :Date f�r DESCRIPfIONOFWORK �,i�.t��,:�4(,,. i'S�� �. NEW � ,�
Coniracto �����
�I am exempt under Sec. f �� ' � �' (�r; .�7,. ADD � � �:(.y.��?f..
! ALTER � �«�'.�.��L
' B.BP.C.for ihis reason '�� � '-� �w- L J......i.i ::....�h REPAtR � s. . r... .�"".
Date: USE OP ... - . �.,.
� E%ISTING BLDG. ' . . 9,'.s h'ti!�... �1+�O1 ❑ , �t-�:�:;�•.L.4�
' Signafure APPLICAM' '� , 7EL - .. ` ;..:., .
OWNER-BWIDER DECIARATION PRIM } :r.l.r^.�:f i..t.'..�� •:,a'��.�...NO. l 1 i' �,:-��3 FlNAI �;!i��,:::�i.G,�
DATE
I hereby affirm ihai I am exempt from the Contractor's License ^' . /' � I,
Low for Ihe following reason(Settion 7031.5,Business and ADORE55 ��E .x � e .. t i .i p�.�„j� F'NA� ,�,,F.'���,—,t,C �
Professions Code): E ENT By
� I, os owner of the ro ert o�m em lo ees wi�h BuitDiNG
P P Y• Y P Y MDRESS
wages as their sole compensation,wiil do ihe work and � . �
the structure is nof intended or offered for sale(Section ����T�
7044,Business and Professions Code). MOVING iEL.
� I,as owner of Ihe properfy,om exclVsively conlracfing CONTRAROR Np.
_ with licensed contmctors to constrod the project(Seo- qDDRESS
tion 7044,8usiness and Professions Code).
_ CONSTRUCTION LENDING AGENCY 5�gq�� YARD HWV T�TAp OP.LCNE WIDTH
�a::�=.�,r,.� �,
I hereby aHirm that there is a construciion lending ogency for FRONT
Ihe performance of the work for which this permit is issued RL � ��'�!��, �,
(Sea 3097,Civ.C.). SIDE �..`'.:' ,
P.�. � t.t,�,��,�!�`',:
Lender's Name .«�
.$ � �� �' 7: L�hL4 Ref.M •���,��,i�r�.�:.
- Lender:s Addreys P.C.fea$ �.�����i Permil Fee .•l.�;� �....
� I,tertify fhat i hpve read this applimtion and state ihat ihe Isauance Fee� '��� ' �'`� LDMA P/C# � 'k�'F����4
¢ frhbove inforrtwtion is correcL I og[oft to�ibmply wilh all Counry Investigation Fee . ( ��- �
,ordinontes and$tale laws r�ting�D 6uildinq canstructiOn, Total Fee�f��1'�✓ LDMA Perm.M
w •and here6y aytho'e repres ntati,�,as of this County to enter
m � upon ihe abqVe�diion,ed�p,p�}ly foyl'nspetfion purposes.
a � ��( / '1""_` -� ;:
� •Y���'PJ"<-+" �., �!r`-.�^1�,,..`,. ' ' ..:�• SFE REVERSE FOR EXPIANATOMY tANGUAGE
-.�.'• '�ignature af Apptican�o±A"vent' Dote �,�
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