HomeMy WebLinkAbout1370 VALLEY VISTA DR (20) I WORKERS'COMPEPJSATION DECIARASION �
I hereby affirm,�,,��e o�e«,f,�a�e of consent to self APPLtCATION FOR BUtLDtNG PERMIT
insura,or a tertifiwte of Workars'Compensation Insuwnce,
or�enifOe�cOop��of(Sec.3800,Lab.C.) � COUPITY OF LOS ANGELES BUILDING AND SAFETY
c F� R ���; �OTS Q�
P❑olicyFo. Company BUILDING
Certified copy is hereby f�rnished. ROP' F�R APPIICANT TO Flll lN ADDRE55 '� �
� Cerlified capy is filed with tha w�nry building impec- BUIIDING���-7Q �fA�.� (STA �..7R tACAUiY
tion.de ent. ADDRESS ! Y
t�. f1�f� NE4RE5T
Date f3C Y� � APPliwn � CITY 1 A�10��y L7r'i r+ Zi7 _ � CRo55 ST.
CER7IFICA7E OF EXEMPiION FRO ORKERS' NO.OF BLDGS. A`��
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PAR�L
(This sedion need noi 6e completed if the permit is for one 8� USE ONE MAP � _ '�
TRACT BLOCK �OT NO. � ��
hund�ed dnllors(S10Dj or lau.) �t. .yi 5vfctnl �
I cenify tha�in rhe parformance of�he wwk for which rh�s OWNER �R ES NO. �7�. CONDITIONS
permit ia tW�ad,I shotl not empVoy any pstson in ony munner DISTRICf GROUP TYFE FIRE PROCFSSED BY �
ADDRE55 (� W��NIRG QWO, CONSL � ZONE V
so os to 6ecome subjact to tha Wor s'Com nwtion Lawa. �v O
�Joa�'7.
Dat f �� APPlicanf CITY L�S ZIP S7ATISTICAI CLASSIFICA APT. CO . �
-*�OTICE TO ICANT: If,�aher moki hia Cerlrfimte of ���� �
ARCHITER OR I�
ENGINEER �LL �� O. CLA55 NO, OWELL.UIWiS__ a
� nption, you chould betome subject to �he Wwkera' �y�7 y
ipanso�ion provisiona of tbe labor Code,yoa musl forih- qpp�55 fb8i5 J (v ART JE, nf SEWER n�wP Z
with comply with such proviaions or this permit shall be tEL. �N VALIDATION
deemad revoked. � COrviRACTOR 1t NO. gK� �''
LICENSE�CONTRACTORS DECLARATION L1C.f(o('���
1 hereby affirm tlwt I am licensed under provisiona of Chapter 9 ADDRESS 3 T NO. VAlUA710N
commenci wilh Saction 7000 of Division 3 of�he Business and uC. / '
Pro{escions Codo,ord my license ia in fufl force ond affecl. Ci7v � • CLASS�b. S '�� ��p .
Aq / sa�. r.�o.oF No.oF _ cHEc+: z 2 4 Q 0 A
licanss Num6er ��!,—`�` Lia Glny. C'b_ SIZE STORIES � fAMIUES OME
/� UESCRIPTION OF WORK TA� NEW � S r{� � � �2`� �
Cantrnctor^LLHe�.I � . �ole ' i '� , , �
❑I am exampt under Sac. �C�f�IR�IC � � �NK A�� � I ��b 5,7 8
.4LTER FINAL
6.8P.C.fo�this reawn S T�'f�'� U REPAIR � DATE I/�l C�.�.� � a_ _�,'7 r,s
ti".]
Dote: E STING BLDG. ��� � gY A� � y,C�1"�`I
SignOtufe APPIICANT TEL.
QWNER-9UIlDER DECIARATION ��NT TI NO. Oa
1 hereby offirm thae!am exempf from the Controctor's License ADoaE55 3 � T��R�E S j • `��. �
Law for ths folkowing reown(Saction 7031.5, Businesa ond .
Profession3 Code): �
� BIIILDING
1, w owner af fhe properry, or my employeee with ,n�0it�55
wogas as their�ole tompanaation,will do 1he work and
�. the structure Is not Intended w offered for wle{Section ���m
7044,Businass and Professione Code�. MoviNG '���
� I,as owner af the propBrty,om ezclusively contracting NTRACfOR NO.
with licansed conimdors to aonstroct the project(Sec- '.�3 Z 5,3 A
ADDRE55
tion 70M,Business and Rofessions Code). ,'7�'� ��a � �
REQU�RED TOTAL SETBACK FROM EXIST.
CDNSTRUCTION LENDING AGENCY g7 gq� YARD HWV pRpp.��NE WIDTH �
I hereby offirm rhat rhere is o construclion lending ogency for FROrit � •5 8 2.�0
1he perFormance of tha work for whieh tliis permit is issued V.t.
tSec.3097,Civ.C.). SIPE � . � °+',�L.r�t�cYi
� P.l.
W Lender's Name Q /'7 ' ��'���8 7
� P.C.Fee S 4 O S 7$ Pe�mit Fee � / .Sv
- lender'a Address /
� 1 certify 1hm I hove read thia application and smre that the �"V'�v
luuance Fee
� above information is cwract.I agree to comply with all Co�nry ���e��gnrion Fea �O g Q O
ordinonces and State laws relaling to building construdion, To�a�p� O K.t
Cf ond hereby avlhorize represenwtivea of fhis Co�nty to entar
� u a obo�entioned propany for Inspecti_n ` A
� (� ti� �I
� ��,41y � SEE kfVFYSi FOiI E7(PIANATORY LAMGUAGE
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