HomeMy WebLinkAbout1370 VALLEY VISTA DR (27) WORKERS'COMPENSATION DECL4RATION ' ` `���Q�C��� �
� I hereby offirm �ha�I have a cenificate of consem ro self APPLICATION FOR BUILDING PERAIIIT �
insure, or o certificafe of Workera'Compenwtion Insurance,
or o certilied copy�herQof(Sec.3800,lab.C.)
WGm�vo3�4 COUNTY OF lOS ANGELES BUILDING AND SAFETY �
VolicyNo. Company��RYH4RooK -
� Certified copy is heraby furnished. fOR APPLICANT TO FILL IN suuo�r�G
ADDRE55 �3`1C� �Avl �1ST4�'ASL
� Cerlified topy is filed wifh the tounty buildin9��gPa�- BUILDING -1
tiondeparemeM. ADDRE55 �3`1Q Vp��6�i V�ST4�Tt
, �ata I�—�`1�S$ ApplicaM CIiY iS.�i..p..�P�+AR ZIP lOG4lITY A�oHP �'41R
CfRTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BlUGS. NEAREST
( COMPENSATION INSURANCE SIZE OF LOi NOW ON L T CROSS 5T.��qTCWp C'C �C�0�9�►1 SPR�NC
(This iection nerd nol bs complafed if the perm{t is fa one 7�� BIOCK LOT NO. ��R
hundnd doUara(S100)or less.� nanP e00U p,q�E vqRc�i
Te�.Z�3 us�zowe r,wv
�certify Ihal in the parformanca of the work for whith this OWNER CABot CA �roV.3GS NO. {"t r,p
perm ir is issued,I shall not employ any person in ony manner A�ORESSg\� N, y V�'o$tivP rit 6 IO�o ���A� �y,
so os to betoms subject lo the Workers'Compsnsation Laws. CONDITIONS �
_. . . V
�ote Appliconr clTv �oy ►dtp.�.S+Y zIP p �
i �TICE TO APPLICANT� If, ofler making this Certificafe of ARCHI1ECt OR TE�• �ISTRICT GROUP TYPE FIRE PROCESSFD gy o
� emplion, yau should becoms subjeN to 1hs Workers' ENGINEER �� [pNST, ZONE E—
Compentalian provi:ions of the Lobor Coda,you must forth- A�E� �a' �a � W
wilh eomply with sueh proviaions nr this parm0 shpll be TEt.L�S STATISTICAt C1A551f1CAt10N qpf. CpNpp, y
daemed revoked. CONTRACfOR �,�q �bp �at I.Ip. 8y(� Z
IICENSED CONTRACTORS DECIARATION ���, CL455 NO. WELL.UNITS-
1 hereby effitm that I om ticensed u�dar provisions of Chopter 4 nooRess 3'L33 PRa f a NO, (7�'�
(tommanting with Section I000)of�ivision 3 of the 8usiness und LIC. ��R�
Professiom Code,ond my licensg is in foll force und eHec}. GTV �"nA CtA55 L�� - - ------ - - VALI6ATION
50.Fi. NO.OF NO.OF CFIECK BK. PG.
license Number ����$� Lic.Class G'�,� 512E STORIES fAMIUES ONE ■
. .. . . ..a DESCRIPi�ONOF WORK 4R Kw..�.�II. NEW � VALUATION �� � �,5 C !. I F_
Conlractw�.v.i�FaQvTO Date.�����'�o '^
T ADU s `�� � ti r s f r`/�",
�I am exampt under Sec } O '� b ��NT
�► �A ALTER � I •�C:;(:t.;
B.BP.C.forthisreacon 5x �Qo �oQ. �o—oR REPAIR � s
Oafs: USE OF , , . _
EX�STING BLDG. �� ❑ � � -
$j �a�y�e APPLIUNT TEI.
9 OWNER-BUILDER DECLARATION PRiM .,� Qeto ♦ N0.��s ` DA E� �-s — I , , � ^��
1 hereby effirm�hot 4 omexompt from�he Comractur'a License u `
law for tha follawinq�reason(SeUion 7031.5,Business and A�DRE55��L�.r+ EL1'Ct4tiV'�Af G $�.(� F��
n.ofess�ons Code): ... . gY
� � BUILDING
I, aa owner of fhe proparty, or my employees with qppqEu
wages as thei�sole compensotion,will do the work and �
ihe structu�e is no�intended or offared for zale(Section �OCAtITv
7044,B�siness and Vrofeuio�s Code�. M�VING TEL.
� I,os owner of�he property,am ax[luslvely[onlracfing CONTRACfOR NO.
with licensed controCtoR t0 consiruQ tha projecl(Sec- pDDRE55
tion 7044,Business and Professions Code).
� CONSTRUCTION IENDING AGENCY seQeACK YARO HWV TOTAPR�BAINE WIDTF/
1 hereby affirm tho�ihere is a construction lending ogenry for fROntT ���1 '
�ha perfo�mance of�he work for which this permit ie issuad p.i. r � �'
(Soc.3097,Civ.C.). SIDE �t�� • �:. `
r i
P.l.
Lendar's Name � ^ �.C�i
m `d +�/ Zrj LDMq Ref.if "
� Lender's Addrasa P.C.Fss f ZS Permi�Fae G C� �.. � _
a
e .-
� I cerlify thof 1 have read this application and stafe that tha lauance Fea �d 5 IDMA PiC M
abova informafinn is wrrect.I agrea to comply with all Counry Imesi�qaion Fee s
q ordinances and State laws relating to building conatr�ttion, Toml Fee 3�� IDMA Perm.M
ond hereby authorize representatives of thia Counfy t0 enter
$ upon i e obove-mantioned property for inspection purposes. �
g ` 11—�4-8�
ue rt�vE�coR�wuTorr u�xsuece
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