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
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