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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 Si run of App�icont a Agen� Dote �� r� N . � � s � Q �� ' � U 1�'L f. � � �Q,,, +� p r `` � ..-._ ^L�Sia w" , O ��p}"' .FC.. U \ ' " a'�� C. „ �' � %:�. �" + °�" G \ t� a �• � a i. 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