HomeMy WebLinkAbout1370 VALLEY VISTA DR (49) WORKERS'COMPENSA710N DECLARATIOf� � �
� insure6oracer�ifko'�e of Workesr,Come°`�°°��'.°e'; . - �����APPLIC�eTiON FO�t BUILDING PERMIT
or o tertified copy theyeof(Sec,3800,} . -�� ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.-'� ' -- 2ompany :'t
� Ce«�f�ed w s hereb turnished. �,, ;; � FOR APPLICANT TO FILL IN �1�lDING 1 �e� v ��'•,t �.. i j' ��f
PY� Y k'i Ao�RE55 �
f�.1' Certified cppy is file h p�� ` ..@U4p�� r� j !' f/, � � -�� �, , �
V lion department�- J:; �y .� ' � �.'J�, ��+ .{�_
. ._ ��rQ.� '�'1�'� .� � I./ � � �� ` � �!l` 21P LOCALITY � �•
Dale ��•���T' Appficanr . . OTV �
CERTIFICATE OF EXEMPTION FROM WORKERS' S�ZE�F�Q7 NOW Ot�1�T- RO5555T !- C-�_�S 4- �.,,.�, i -� - �-�' �
COMPENSATION INSURANCE
(This secfion need not be completed if tha permit is for one 0.55ESSOR
hundred dollors(5100)or Vess.� TRAQ BLOCK LOT NO. 44qP HOOK PAGE PARCEL �
OWNER � ��`� F �r � TNO. ' . USE ZONE P ` � ' • � ST '7 V
I certify thal in�he performance of the work for whith ihis �'
SPECIAL
permit is issued,I shall nat employ ony person in any monner pDDRE55 �"' ' t' � CON�ITIONS "�
so os to become subjec�to�he Workers'Compensation Lows. 1i
CITV . ' ZIP � � �
Dote ApPlicont ARCHITER OR TEL.
NOTICE TO APPLICANT: If, afier making thi5 Cenifica�e of ENGINEER Np DISTRICf GROUP IYPE FlRE PROCESSED BY ¢
Ezemption, you should bacome su6ject to the Workers' . . '7 CONST. ZONE / (�
Compensotion provisiona o4 tha Labor Code,you mus�foNh- qppRE� f ' � �:'/ �
Q.
with comply with such provisions or this permit shail be TEL. STAt15TICAL CL4551FlCATION A�T. ;CdNoO. �
deemed revoked. CONTRAttOR - � � - NO. i W
LICENSEO CONTRACiORS�ECLARATION ���_, - CtaSS NO. � � DWEu.UNITS �
1 hereby affirm thnt 1 am liceened u�der provisiuns af Chapfer 9 ADORE55 " NO. � ` ��R�
(commencing with Section 7W�)of Division 3 of the Business ond � LiC. _. "
Professions Coda,and my�icense is in full force and effed. CITY CLASS� BK � YALIOATIOIi
. 50.FT. NO.OF NO.OF CHECK
License Num6er � lic.Closs - SIZE STORIES FAMIlIES ONE
�" � v�►unnoN
""-�='�'�_�_'°"'/ DESLRIPTIONOFWORK �W � �
Conhactar� -' � Date f ;�(:�,� ' , .- �
� ; ;.1 "°° p
�I am exempt under Sec. ��T'-���'� � AL7ER �
6.8P.C.for this reaso� REPAIR s � f n
USE OF r.•Y:1�i..l K
Date: ! E%ISi1NG BLDG. �� � '�'
' :'- . . . � :'�:•?.�../� APPLICAM TEL FIN14L d �t!!i!:�.L s;
Signature -` .. � PRINT NO. DATE I/���-r •.-`�'�.. .
OWNER-BUILDER DECIARATION
1 hereby affirm�hu�1 am exempt from the Contractor's License � f„�'s„','a��
Low for ihe followiag reawn(Secfion 703L5,Busineas and P.DDRE55 HNAL � • �
� Profeseions Code): sy � �����;�-��.��l.4
❑ ewininrc ,
I, as owner oi the property, or my employees with ADDRESS .J,�.�.,�,^;[;,C/'
woges as their sole compensdtion,will do the work and ���� �
fhe slructure is no�intended or offered for w{e(Section
7044,Busineu ond Rofessions Code). MOViNG TEL.
' � I,as owoer of�he property,om azcl�sively contmcting CONTRACTOR �� .
with IiCen3ad coMrxtors 10 GonshVtt}he projact(Sec- qDORE55 ��4�;•r;�,��;
tion 70{4,9�sinese and Professions Code�. � '` � �,
REQUIRE TOTAI K i;�,!i�,e�Z, �
CONSTRUCTION IEN�ING AGENCY SEi BACK YnRD HWv PROP.LINE wioiH '
I hereby affirm thot there is a constructio�lending agency for pRpNT L:!.,�,y:,G��:� �
Ihe performance of�he work for which this permi�is issued v.L � I
SIOE r.������`
. (Sec.3097.Civ.C.). � ,���t� i;{.
v.�.
lender's Nome
�� ���. LDMA Re4.M �'.i�.S.:�;Z:Cf,
� Lender's Add�ess P.C.fee S I Permil Fss '
� I�ertify ihot I hove�ead this applicalion and itple that the Issuance Fee LDMA P/C M
� obove infwmation is cwroct.1 ograe to comply with all County �nveaiigotion Fee
q ordinancas ond State lowc ralating�o b�ilding construction, Twal Fee IDMA Perm.M
and here6y authoriza rapresantativat of this Counry to enter
upan tha obova-mentPned property for inspedion purposes.
< . -,;'��;��-,f�f;� �' /f ',� fii ifVfllfE fOi EXPIANATORY LANfiUAGF
r '�Siqnoture of Applicanr or Agent Doro �
.•�!
.•
�' � �
�,.�: .
�,�';
: .a-.
�+•� . .
:� �e
.:v-,�:��` ., . . �
',�,, - .
�..�_; .. ' . .
, r�` ' .. �
}.. . . .
.�- } ` � . �
, ` ..
, � .
�', �;,
' � ,i� +r� '
. .:�,
';
t t�
,Y
+ ��