HomeMy WebLinkAbout1370 VALLEY VISTA DR (13) WORKERS'COMPENSA710N DECLARATIOf� � .
� 1 here6y affirm fhot 1 have a cer�ificate of�a�5a�„o 5e�f ��`���qpp��C�4T10N FOR BUILDING PERMIT �j
insure,or a certifim�e of Workers'Com r ce�
or a certified copy theyeof(Sea 380p,} . � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.—'� ' �- 2ompany :'t
� Cert�F�ed wpy�s hereby furnished. O� �,, ;; k�� FOR APPLICANT TO FILL IN BWIDING � �r� v ✓� `� �, -�, ��r
��. Certified cp is file h L'{q-���? 1�� . Ao�REu
lion department�-.. 9 i ;Y,w''�i. P�Fq ..Bm�A��,,fr- ,t' �` ;��. .{;_;i Y .
:'�'^..--• ��r3'.��'� �i � i
Dale Applicant CITv .-•� � � �� �!� 2iP �OCq��iY � �.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.oF aLOGS. r�qRESi
COMPENSATION INSURANCE 5¢E OF LO7 NOW ON l0T CRO55 5T. :� t"�-��� e �..,.r i = :-_I-<'f
(This seclion need not be completed if fha permit is for one TRACf BLOCK LOT NO. �ESSOR
hundred dollars(51pp)or less.) NWP 900K PAGE PARCEL �
OWNER � �"� 't ?' T�,�p. ' • USEZONE �P V I I • � 5' O
I certify thal in�he performqnce of the work for whith ihis ryp, � V
permit is issued,I shall not employ any person in any manner � t, : � ���q�
so as to become subjecl to Ihe Workers'Compensafion Laws. A���� ��� � CON�ITIONS J
Dote Applicont CITV . ' ZIP � � �
0..'
NOTICE TO APPLICANT: If, afier making fhis Certifitote of ARCHITER OR TE�� DISTRIR GROUP IYPE FIRE PRDCESSED BY ¢
Ezemption, you should bacome su6ject to the Workers' ENGINEER NO. �p�T ZONE
Compensation provisions of the La6or Code,yau musf forlh- A�E� � ' � �. / O
with comply with such provisions or this permit shail be � � �:'/ �
daemed revoked. i � NO. � STAt15TICAl CL4551FlCAilON qp7, .;CQNpp. �
CONTRACTOR -
LICENSEO CONTRACTORS�ECLARATION ���_ . CIASS NO. � � DWEtL UNITS ? H
I hereby affirm thot I om Ircerned under provisions of Chaprer 9 ADDRESS - - � - ryp � � -
(commenting with Section 700�)of Division 3 of the Business ond �� . SEWER hVN
Professions Coda,and my�icense is in full force and effect. C�TY � CLnSS� -" VALIDATION
� - 50.FT. NO.OF NO.� CHECK BK. pG.
License Num6er � lic.Closs - SIZE STORIES FAMIlIES ONE
Conhactor' -� � pate��-,�"�.~���.-::�-�� DESLRIPTION OF WORK �W ❑ VALU,ATION
❑I am exempt under Sec.— '��"/ !�% • . . ._ j i ;�� AOD � S ' � �- �
ALTER �
6.8P.C.for ihis reasOn REPAIR s
USE pF � 'Y
Date: ExI571NG BIDG. DEMOL c..Y:t��..1 11
Si nature .: .�.'- � - .i i i:•r./.., , �
. 9 � APPLPG IM TEL FINAL Ji.!�i!:�.L�;
OWNER-BUILDER DECIARATION N�' DATE ������'
1 hereby affirm�hu�1 am exempt from the Conhoctor's License � f;,��s,;;�(��
. Low for�he followi�g reawn(Section 7031.5,Busineas ond ADDaE55 F��A�
Profeseions Code): By r �:�,s!r;�.��,4
� I, as owner of the o ert or m em lo ees with BUitDiNG "'
W P Y, Y P Y ADDRESS �.0,t.�._;��
woges as their sole compensotion,will do the work and � �
ehe structure is not intended or offered for wle(Section ����Tr
7044,Busineu ond Rofessions Code). MOViNG TEL.
' � I,03 ow�er of the proper�y,am axtl�sively contrec�ing CONTRACTOR �.p.
with litensad coMrxton to conshVtt}he projact(Sec- qDORE55 ,.,4;��;j„(i�;
tion 7044,9�sinesa and Professions Code�.
CONSTRUCTION IEN�ING AGENCY �QB qK YARD HWv TOTAt c r.������ � I,
PROP.LINE WIOTH . . ��
I hereby affirm ihot there is o construUion lending agenq for FRONT �,. �
Ihe performance of�he work for which this permi�is isaued v,L [".��,i;G�A, i
. (Sec.3097.Civ.C.). S�p� .
v.�. r�r��^ w
lender's Nome C '' ''�"�'�`'t'
m Lender's Address P.C.fee S "�•��41 Permil Fes � - LDMA Ref.M .('.i�.�....Z:Cf
a 'p I certify ihot I have read this applica�ion and stale that ihe issuance Fee LDMA aiC M
' obove infwmation ia carect.1 agrae to comply with all County �nvsaiigotion Fss
'q ordinancas ond State lowc ralating�o b�ilding construction, Twal Fee IDMA Perm.M
and here6y authoriza rapresanfativat of this Counry to enter
upan tha abova-mentPned property for inspaction purposes.
m � ",�'r�'� �� �f '�I Sii ifVfllfE fOi EXPIANATORY LAN6UAGF
.,''
" Siqnature of Applicanr or Agent po�s �
.•�!
.•
�' � �
�,.�: .
�,�';
: .a-.
�+•� . .
:� �e
.:v-,�:��` ., . . �
',�,, - .
�..�_; .. ' . .
, r�` ' .. �
}.. . . .
.�- } ` � . �
, ` ..
, � .
�', �;,
' � ,i� +r� '
. .:�,
';
t t�
,Y
+ ��