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HomeMy WebLinkAbout1370 VALLEY VISTA DR (21) WORKERS'COMPENSATION DECLARATION � � I hereby affirm�hat I have a certificote of�o�=e�,,o self APPlICATION FOR BUILDING PERMIT inaure,or a cerrifica�e of Wwkeri Compensation Insurance, o�a certified cop ther of�Sec.3800,Lob.C.� ��dy e���� N•ttYw4�t+oK COUNTY OF LOS ANGELES BUILDING AND SAFETY��� j' Policy Na. Company BUIIDING � Cerrif�ed copy+s he�eby f�.��etied. FOR APPLICANT TO FILL IN ADDRESS \3`l 4 �q��er V�S'ra� � Certified copy is fifed with the tounty 6uilding inspeo- BWLDING tiondeparfinenf. AUDRESS �j`�O A��� \1Tp �0. Dale����d��$ APPIicoN `"� pTv�`�� o�..�¢ q17. ZIP LOCALITY Y t�t^�O Q ��AC�. CERTIFICATE OF EXEMPTION FROM WORKER$' SIZE OF l0T NOW ON l0T �5T.G AC'SW C Gt��vC.�SPp.Vyfy GOMPENSATION INSURANCE (This section need not ba completed if the permit is for one 7Rp,C7 BIOCK LO7 tJO. �� MAP BOOK iAGE PARCEI hundred dollors(E100)or less.) TE�, i\ OWNER GPR. Ca G�R Np. 2 +a11� ��ZONE MA7 I CHAify Ihat in fhe parfarmance of the work for which this �'1 �� permit is Issued,I aholl not emplay any penon in any monner qpDRE55 � W��. QG��"io�L4 ��\a. pND1TIONS � w os�o becoms subject to�he Wake�s'Compansorion Laws. p GTY a, M{bwiS ZIP E?@�`� V Dnle Applicanl LL' ARCMItER OR TEL. DISTNICT GROUP ttVE FIRE PROCESSED 8Y `� 7TtCE TO APPLlCANT: If, after making Ihis Cerlifieote oS N INEER NO. CON57. 20NE � � emption, yau shauld bemme subject to fhe Workars' V . � 'wmpensation provisions oi the Labor Code,you must foAh- pppRESS �+1 with comply with such provisions or this permit shall be _ .. ._ ___ _ . fl. � TEL 'L.�� STATISTICAL CtA$SIfICAT10 APT. CONDp. N deemed revoked. . cOn�ta.eROR a,e..A.y�T�'i`�wTtt NO. � tS� � r� z LICENSEDCONTRACTORSDECIARATION �i�, CLASS NO.�L��WEtL uwTS_ I hareby affirm that i am licenseci under provisions of Chapter 9 ADDRE55�Z,'i�j Q`aTGRT R�i�'s F70. �o\�1`iZ (commencing with SeWion 7b00)of Di�ision 3 of the Buainess and L�. SEWER MA9 Professions Code,and my license is in full forca o�d effect. CIiY "��+i"n'A CL455 G"�b BK � YALIDATION A SQ.FT. NO.OF NO.OF CHECK License Numbar,���$Z' Lia Clau�`+`� SIZE S70RIE5 FAMIUES ONE t� vnwnnoN Contractor�l��rs+'[� .Dofe ����{��� �xRIVT10N OF WORK �3'P'C\�-tV�`�N. �W ; �S l ,�.+ AOp �� ❑I om axampt under Sec. �C'Hd} 4a �10►�•►'r ❑ � AITEfi 8.8P.C.for�his reason "�4'�� ��'F« ��,� REPAIR Q i us�oF Dara: ex�snnrc a�. �� .� �SignoNre APMICANT �� TEL. 't,\�, fIHAI � �� t.=F� OWNER-BUILDER DECIARATION PRINT I��q�.aA�r't�t�tr1�� NO. ' g� DATE�^�� _ }t a a o . IherebyoffirmrFwtlamexemptfromtheConeraetor'slieansa pooaess3z3� EwY61.R¢�SC �Vh"a► � Law for ihe following reaaoa(Soction 7031.5, Buainess and F� � a s��� , Profassions Code�:� ���� � 0Y � � BUItDING :« o �.. .. , _ I, as owner of fhe property, or my employees with ADDRE55 woges as their sole compenwtion,wilf do the work ond � Ihe slrocture is not in�ended or offered for wle(Sec�ion �aA��TY � ,.I �- .. 7044,6usineu and Professions Code}. �nOv�hiG 7EL. � I,os owner of the property,am exclusively coniracling � �RAR� �' wifh licensed conhactors Io conctruct the project(Sec- ADDRESS tion 7044,Business and Rofessions Coda). CONSTRUCTION LENDING AGENCY gQg� YARD HWY T�tApR�pp,�INE WI�TH •_.`,c i.I� I here6y affirm ihat there is a consiruction lending agency for FRpryT the performance of the work for which ihis permit is issued P.L ;,.'• • a . � (Sec.3097,Civ.C.). SIDE v.i. I G n 3 C�, Landsla Name - �a.s S �! LDMA Ref.11 - � - $ Lander's Addrest P.C.Fee f Z 5 Ps.mit F�� L O.s� � s . .:�, I � I terfify thot 1 hove read thla epplication and siate that�he iuua�xs Fm � � IDMA P/C M � i.C I "_.. above in(ormafion Is cortect.I agree to compiy wlth all County Inveuiqation fee !�,p $ ordinances and Sta�e laws relating�o building conshuctian, Total Fee 3 6 � �pMq Perm.M and horeby authorize rapresentatives of this County to anter $ upon he obove•meMioned property for inspection purposes. ^ `J .v,_�� y.q �\�`4-g�y SFEYFYERSEFORiXPLANATORYtANGt1AGE SigrwNro of Applico w Ag�nt puM �: ; .•'. �-- � rr y s ', ,..� �.. /" � � o a�i c � � � ' 'i e ,'�,,`� `"�u 't,k " i.) - a..: ^ . t q G � �4..=. ,- 't5:s =-�"� }� ?. � y m' �'.��(- � � !.«^ �� 'J lJ" o � u S N� p sG. r O �,� c JI+ m ? . '': +` N '.� F ,�,` �� �� s 1' �".^.. �� Y y.Z £ �7 ¢,.' G..l-. � Q y "' _ S �. �� y w . CY ��r' ��{ q; �J� ^ .�..Li '��'^'[`'+� 4 7.G;'��� ♦ �, . � ":� �F v r�^.Y:: �` � N � ' �^w^� �. 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