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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 � ,f. . � ;�� � . .� � ,, N C "+ i �G��� � , r _a�� c�G.�°��'� =c°? oatioc5 C�, �,d a o�, o@ gi. y a ta G. � � tL ..y�6����� nicR�' �.~ � oa °G G . aL�y��GA v�H�m�m� �y,V�o C f� s� ''N , �� ' �bq�cwn�.,ia�yz� � o��'i, ..3 m:. �'c�mC4l��v"�i Q v�r iy : . 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