HomeMy WebLinkAbout1370 VALLEY VISTA DR (42) 1 � WORKERS'COMPENSATION DECL4RA710N S��
'I hereby offirm that 1 have o«<,;f,�a,e of consent to self APPLICATIQN FOR BUILDiNG PERMiT �
insure,or a certificate of Workers'Compensotion Insurance,
ar o certified cop thereof�ec.38�,loG C.). COUNTY OF LOS ANGELES BUILpING AND SAFETY
W C c►�oe�a�d�e3 No¢�+a�tti.00�G
Policy No. Company B��yyG -`
❑ Certified copy is hereby furnished. . - FOR APPLICANT TO F0.L IN - qooeess ,��G�ii�'�-`''r.�4 1 S"C
�, Certifiad c ia fSled with the coun buildin ms o- ����' +� `+ � �( -^�
�PY �Y 9 Pe ADDRESS,?rI'Q �1'A`\7S^) V►ST<i�� Yvv�F-�.i, �?��
tion department.
Dafe��`�..�_�d A IicaM���``����"a dn ��`ZIP COCALITV
PP NO.OF BL�GS. NFqREST �
CERTlHG4TE OF EXEMPr10N FROM WORKERS' S¢e oF l0T riow oN�Or CRO55 S1.
COMPENSATION INSURANCE qSSESSpR
(This section need not be coMplated i{the permi�is fo�one TRAQ BLOCK LO7 NO- lAAP B�OOY PAGE PARCEL
hundred dolla�s(S100)or{ees.) �t..e;�.�'��� t75E ZONE /�P
� OwNE cz^ Ltl�'�'+..c NO.
Y cerlify tha�ir+ihe performante of ihe work for whith this gpEq,q� a
p6rmil is issued,I shall n0/Cmploy any peraon irt arry manner ADDRESS� �o ��{id1.µ�.�'�-++O'�'p CONDITIONS �
so as to hecome subjact ro the Workers'Compensation laws. �p� p .- .-..-- ----- -- � U
. CIN Hti `Ji�j ZIP Z O���
_ �
�nta ApplicaM ARCHIIECT OR �L. �ISTRICT GRWP TVaE FIRE aRO�SSED BY O
NQACE TO APPUCANL lf, ofrar nwking�tfiis Ca�ificate of ENG�n�ti NO. CONS ZOtu� �
Exemption, you ahould bacane svbiect to the.Workers' � U
Pe P Y �� � l N
Com nsation rovisions of the lnbor Code, ou must forth- ��u
wifh comply wifh such prov)sions or ihia perm�i-shall be �pNT ROR -� No. Q STATISTIG0.l C1A551FICA710N nPr. coNoo. Z
deemed revaked. . - �
LICENSED CONTRACTORS OECIARATION UC w CLASS NO. DWELI..UNITS
ADDRESS 3�� � �S ��Vd,7��`
i hereby affirm rhat i am licansed under provisions of Chopter 9 ��� - $EWER MAP
(commencing with Secfiort 7W0)of Divi�ian 3 of the Business ` VAL{DAT{ON
and P�o4essions Code,and mpy licer�s.e is in fv11 force and effect. �Fr �� � �•� �� ��E� aK. PG.
License N�mber��,��o� Lic CIp55 �^�� SIZE`�ad �ORIES FAMILIES ONE
�+ VALUATION
ConfrociOr���i��"Zr.-D?te �p��,�O • �ESCRIFRIqJ OF WORK r\�� �Q�-� N� � .s. ��S
�`T� �, � ADD
❑1 am exemp�under Sec. �� ��R ❑ .•.. -- - - - � 3 7 Q�,9 A
B.&P.C.for this reaaon REPAIR 0 s � •f�y,�
USE OF ��' � r
Date: EXISTING BI�G. DEMOL❑ 2�O O
Signolure �pRC NST NO. " Q. 2 y r
� � FINAL�
OWNER-BUIIDER DECLARATION ( � �'p � DATE � �r y Z�O O�
I hereby affirm that I am exempt from the Contractor's License qppRE55 �3�j '�+�i• s[�LUS� ��� F�F{h� ,
Law for the followinq reason{Section 7031.5,Business and ��,��/ 0�D 9"8 9
Profeilions Code): � PFESENT . . - -- - By---- ��"� -
BUK�ING
❑ I, as owner of ihe property, or my employees with ADDRE55
wages as their wle compensotian,witl do the work and �aAun �
the strutlure is not intended or offered for sale tSection
7044,Bwines�and Profeuions Code.) MOH�NG TEI.
❑ i,as owner of the property,om excfusively conMacting �MRACTOR NO•
with licensed conlroctors to Consir�ct the proiect(Se[- qDDRE55 �7, �7 A
tion 704a,Bosiness and Rafessions Code.} _ �
RE(aU RED YAR� HWY OTAt SEfBACK FROM EX15T.. #�t� i��
CONSTRUCTION IENDING AGENCY 5E7 BACK P P. INE
I here6y affirm thot there is a wnatrntlion lending agency for fRpNT 2�r 3 0,5 0
ihe performonce of the work for which this permit is issued P���
(Sec.3Q4T,Civ.G). 51�E •! •3 n�J G=
P.l, V
Lenders Name ���p Z 6.+p 4� l�AAA Ref.N 0 51 1 -8 9 ;
� P.0 Fee E Z r� Permir Fea
Lenders Address
� I certify that I have read this application and state that the Iss�a�ce Fee ���s� ��P2 N
' above information is correct.I ogree to comply with all County Invesiigar�on Fee �j
gordinances and State laws relating�o boilding corrstroction, io�oi Fee 7 0��� IDMA Ve.m.#
� and reby rize represe tives of fhis County fo enter
ihe ve- ti rty for inspedion purpases.
� �'S9 SFF REVERSE FOR ElIP1.ANATORY LANGUAGE
I~ Signature oF App�imnl or Agan Da�e �
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