HomeMy WebLinkAbout1370 VALLEY VISTA DR (39) 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
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