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HomeMy WebLinkAbout1370 VALLEY VISTA DR (26) WORKERS'COMPENSATION DECLARATION � � ' I hereby affirm tFwt l have o cenifica�e oi consenl�o=e�f APPLICATiON FOR BUILDING PERMIT inaura,or a certificate of Workers'Compensation Insurance, or a cert�t�ed copy theraof(Sec.3eoo,�ab.C.) , COUNTY OF l05 ANGELES BuILDING AND SAFETY � PolicyN��IIID�F'Y��mpanyS�P�z►� Na���., _ e��J Certified co is hereb fumished. BWIDING c� PY Y FOR APPLICANT TO FILL IN -- nooRess 13 O I/ VR���,.� Nh. Q Ce�lified coBY�s filed with the county b�ilding inspec- g���p�� /� /p � tfon deparfmanf. ADDRE55 � lJ � Data IO—l ' qpplicant_N'Bix�1�4Ti CI7Y LP lOC4tITY �Q.�,..��.� Q.st� CERTIFICATE OF E7(EMP710N iROM WORKERS' SIZE OF lOT NOW ON LO7 NEAREST COMPENSATIpN FµSURANCE �j CROSS Si. (This section naad not be completed ii the perrt�if if ior one TRACT 3� ' BIOCK l0T NO. Y¢� A��R hundrad dOlI01II(5100)Of leM.) htAP 900K PAGE PAR�I �zo� � (—33 3 I certify that in the performonce of the work for which thia ��R � � � NO. �r permit ia i�5�ed,(ahal)not employ ony person in any monnar qppREu s, L �1( �I..! SPECIAL �, so os to become wbject ro tha Workers'ComF»nwtion[awe. o �°� � � CONDIbOniS � ciiv 3 zir v Dote Appiicont _ �. � -'�TICE TO APPIICANT: If, ohar making�this Cerlifimte of A'������ TE�� _ DISTRIQ GROUP NVE FIRE PHOCES.SFp BY O emption, you ahould become eu6jeet to the Workars' INE N NO. . ZOrIE � Lompensalion provisiarn cf fho Ia6w Cod�,y0u must forth- qpDRE55 '� t, 1(� J(rf�y(� j d �1 . U �( wi1}r comply wirh �uch provitions or this parmit ehall ba �''� desmsd ravoked. � � STATiSTICAt CIASSIFICATION qpT, �� IICENSEO CONTRACTORS OECLARATION CONiRnCtOR YIA�t Wl S�+t�� ,Z(3C��J4"TR � y� � Z 1 hBre l t y a f firm t h ot 4 am lice n s e d u n der provisions o f C F w ptx 9 ADDRESS ��'M�@�L�a'W G t O. �j���?7--- ��� OWELL.UNITS (camme(uing with Senion 7000)of Division 3 of the Buslneas ond �� ��- ��� R SEWER MAi Profeaions Gode,and m licenaa is in full fores ond effx�, Cttv C1A55 'J YALIDATION ! SO.FT.. NO.OF NO.OF CHECK BK. PG. Lieensa Num6er ��`��� l(c.Cfoss_.-� � SIZE 1 STOftIES � FAMIl1E5 ONE Gonrracror A1 rn"rwW i�utM pata -q0 DESCRIPTION OF WpRK �yJ Q VALUATION '/ ,,op � s 2(� 80D � ❑I am exempt under Sec. , ('�{n A�hR z Q Q��i A 6.8P.C.far this�wson �����(�r�+, j REPAIR o,�B: us�oF r � � #• • • •2 3 E%ISTING BLDG. e,Ci Sipnaturo AP°���r �,` T�t FINAL I • 1 5�8 5 OWNER-BUILDER DECLARATI�N 7RINT Np, � � I hereby offi�m that I am exempt from fhe Contractor's Lite�ss qDDRE55 Z��l� �� �U 0 4��+.f ,(�)���,�/ DATF .7, �j •• � �3,��J� Low for fhe 4ollowing rcason(Sacfion 7031.5,Busineas ond FIHAL Profeulona Code)� gy / 0 7.2 2—B 8 � � euiioiric I, as owner of�ha propetty, o�my employees with ADDRE55 wpye�as their sole tompanwtion,will do Ihe work and � the structure ia not intended or offered for wle(Sec}ion ����TY 704q,Busineas and Professions Cods). - MpVMG TEL. � I,os owner of the properfy,am exclusively controtting ��TRACTOR NO. with(icensed comracton to construct�he project�Sec- qpDRE55 tion 7044,B�siness and Roiessions Code). � REIXJI D TOTA1 TBA K CONSTRUCTION LEN�ING AGENCY SET&4CK YARD MWY pRpp.�INE WIDTH I hereby affirm�hat�here is a construction lending agency for FRONT �2�+`y� � �he performance of the work for which thie permit is issued P.L. ($ec.3097,Civ.C.). SIDE V.L. jI•!� a >'� Lendar's Nome f � LDhW Rei.M I • � C���l; W Landar's Addross P.C.Fee S (� Permit Fee .� � - � I certify ihm�have read this application and siate thot the iss� /(��� � 1 Y i ' � ", ance Fee IDMA P/C k 9 obove informo�ion is corrett.I ag�ea to comply with oll County �mea��gation Fee / � �,C%—�.R � ordinances and Stote lows reloting to 6uilding construction, Total Fee / J•� V LDMp,perm.M R ond hereby authorize representatives of�his Counfy to enter upon the aqbovo-me on property for Inspectio purposae. ,� � ! /��f�M���'^� !� ? SEE RFVEYSE Fpt EJ(pLANATORY IANGUAGf Siprw�Lrs of ApplimN or Aqenl te r ,-- s � � s �-� �, V,�•�'� y� w0 V � 1K �Lia�� n�V w�,^ � �, m�O �. C G p v Y �„'�-.� p, . . S'l7� F '� u N c' � N G Q � � Ci.l'.+•Y. i X' A*a�, w . c, - -'� o o ,,. r o . ..' ca � . . L ���Y.. '� r V r- »�.�"Z � y p,.i c.�i- a' C� Yi o� '� C f w F Y; ti� 6+`; � ,..L:. . . � � ps z�'C 4a„ r Y �.. ., M.o. ,.. .... v+ a. `O ,=..'�S� r. : �. 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