HomeMy WebLinkAbout1370 VALLEY VISTA DR (28) ' �RKERS'COMPENSATION DECLARATION
��,a.ebY a,.m ihat I have a certifiwte of�o�te�,,o,a�f qpp��CAT10N FOR, BUILDING PERMIT �
= ins�re,or cerlificala of Workers'Compensation Insurance,�
or o cerrifi copy rheroof(5ec.3Boo,�ab.C.) C4UNTY OF LOS ANGELES BUILDING AND SAFETY .
�"Po6[yNo.` .. �. .,'+ Company_!.�. _ ' .. , „ ..
� Cert ed copy is hereby fumiahad. T FpR APPLICANT TO F1LL IN ' B���oiN� - �''"
ADDRE55
, n Cer ied copy ia filed with the coumy 6uildin9 inspec- BUIIDING = — .. „
� lion aparfinent. ADDRE55 �
Date � Applimnt �. "�` CITY*+ " 21P IOCqLITY .
E IFI T OF EXEMPTION FROM WORKER�S' NO.OF BlDGS. NEqREST
COMPENSATION INSURANCE .. SIZE Of LO7 NOW ON LOT CROSS ST.
(This aecti need nof be complefed if the permit is far one TRAR BIOCK tpi n�p.� '�FSSOR
hundred Ilan($1W)or Iwss.) MAP BOOIf PAGE PARCEL O�
1 cerfify t t in ihe performancs of the work for which this OWNER^ _ — Np ' USE ZONE � , U
parmir is fsued,1 shall not employ any person in ony manner _ � . ��w�
so as�o �oms sub'ect to the Workers'Com enaation Laws. A�oRE55^. - _ �
I P ` �� "� CONDIilONS ..W.�
�
Dofe Applimof [4TY� . _ ZIP n, }
NOTICE APPLICANT: If, aher makin this Certificale of ARCHI7ER Ott TE�, �
Easm tio, 9 _ 1 �;� DISTRICT GROUP TYpE FIRE %20fE55Ep BY
p you should 6ecome subjed lo the Workeri ENGINEER NO. �pµST. ZONE
Compensption provisioos of the lo6or Code,you must fortb- qODRE55 ., - � f�� ��` . ` p
with co ply with auch provisions or this parmlt shell 6e - ,��' �� � 1� L,� �f
deemed evoked. TEL. �` STATiSTICAL CL4551fICATION pp�. �pry
CIXJiRAC70R�` NO.- i � W
LICENSED CONTRACTORS DECIARATION LIC. WSS NO. �' � DWELL.UNlis �—
' I hereby ffirm thot I om{icensed under proviaions ot Chapter 9 AD�RE55 , _ NO.�. .
(mmme 'ng with Secrion 7000�of Division 3 of tha Business and ��� SEqupR Mqp
Ro(essi s Code,and my license is in fuli tace ond effen. Ciiv - • CLASS �.` . VALIDA710N
I SO.Ff.T NO.OF �.�p.pF CNECK BK. pG.
license�1umber � - - Lic.Class=m-�—- �ZE � SiOR1E5 FAMILIES ONE
� '� ..:. N� n VALUATIOH
Coniractprh � �.�, . po�e ___ �ESCRIPTIONOF WORK C. - - �y4 S
ADU ❑ �
� ❑I am ezempt under Set. ; _ � a y �,,
� AITER
B.BP.C.for this reason � ' � REPAIR � s r �:(,_j±%`, � '
� �o1e: E� �... �. ,
EXISTING BIDG. DEMOL • ' �-
Signature APPl1G4M TEI. �, • Y.� •��i,
caiNT pp FtPfAL t . ��%{�.;•
OWNER-BUILDER��KIARATION DATE
, 1 hereby aHirm that 1 am exempt from the Canirac�or's License � � - "
law for Ihe following roason(Section 7031.5,8osiness and ADDRe55 FINAI !���, �'.[�; �
Profeuiona Code): � �'
� 1,ns owner of 1be ro er or m em lo ees with BUIlO1NG ��� j,���,^: •
P P N� Y P Y ADDRE55
wafles as their sole Compenaation,will dp tha work ond �
�he strutture is not intended or offerad for sale(Secfion IOCnLITY
, 7044,Buainesa and Professions Code). MOWNG iEl.
� I,cs ownar of Ihe property,am axclusive�y confrotling CONTRAROR NO.
with licenaed controctors to conatr�cl the projecl(Se<- qODRESS
tion 7W4,Businass and Profeuions Code).
CONSTRUCTION IEN�ING AGENCV �gq� VAR� NWv T�TApp��INE WIDTii
I hereby affirm rhof there is a tonstrucfion lending agency for pRpryT
the perfwmance of the work for which thia permir is ieeued p.�, �
(Sec. 3W7,Civ.C.). StDE r
P.L. .. i L l.., h.
Lende✓s Nome i �,����;
'$� LDAAA R�f.M � .
LpBCjar's Addreat ' P.C.F��S Permit Fee - , 1.�,�.�'w t;C�:
� I canifK that I have read thia appllcatlon and atote that the ' iuucncs c.e Mp PiC M t��• �
above informotlon ia corcecf.I apree ta comply wIM all County Invutiqalion fw .��. ��.i'�'�-
$ ordinoncaa ond Slole lawe relating fo 6�ildinp conslruetion, Toml isa LDMq pmm.k 4
R and har�by a�thorisa roprossnlotive�af thi�Counry to eMer � i,,'J.�—f.�'•
� upon tho abpva-menrion�d propeny tor inapeclion purposss. -
� Y r/
„ _;�: ���" fii tiViNfE FOi UULANATORY LANGUAGi
Siqnmuf►of Applicant or Apent, '+ ppN
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