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Home My WebLink About1217 PORTO GRANDE WORKERS'CO.MPENSATION DECLARAiION � I hereby offirm �ha�I ho�r.n certiFicate o�consent to self APPLICATION FOR BUILDING PERMIT Insure,or a teriifica�e of 1Yorkers'Compr,nsotion Insu�ance, or a ceriified copy�hereof(Sec.3800,Lob.C.) . vOcyNo.121832-$ Com�o�y Plission Ins. COUNTY OF LOS ANGELES BUILDING AND SAFETY pv v FOR APPLICANT TO FILL IN nooacss Ccrlified co is hereb (urnishrd. �� G1...CJ'�'• � Cenified copy is filed with the co�nty building inspec- OUitDiNG lion dr.parlmenl. ADCR[55 1217 Porto Grande Dr. iocnurr .�; �rt�v AEAREST oa,e 6/30/83 nPP�;�o�i C.�DeI1�se aTv Diamond Bar z�v cRoss sr. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. n55ESSOR COAIPENSATION INSURANCE SiZE OF�pT NOw ov�Oi fnnv BOOK PnGE PARCEL (This secrion need nor be cempteied if thr.permit is for one u5E �.^aP ��,�� hundred dollars(5100)or less.� TRACT 42536 BIOCK LOT NO. �� NO. TEL, $PECIAL I cerlify thol in the pnrformance of�he work for whith Ihis OY/Nf2 Presle Of 50. Cd�.1f.No. 540-05 �/�"�� CONDITiONS �u� �'r�'3 ti ermil is issued,1 sholl noi em lo an erson in an mannM DISTRICT GkOU7 TYVE FIRE PROCESSED BY � P P Y YP Y ADD2E55 P.O. I30X ZZOO CONSj,� 2�NE V so as to becomn s�bjr.tt lo thc Workers'Compensaiion laws. /0 �� C ciTv [Jet rt I3each z�P 926G3 � Date' Applicant STATISTIG4LCLASS�FiGn110N A7T. CONDO. F- ARCHITCCT 04 TEL• O ,l V NOTICE TO APPLICANT: li, aRer makinp this Ccrtificate of ENGINEER F�nil Benes r,o838-6680 CIASS NO. 3 DWELL.UNITS�T � �+ Exempiion, you should becomo subject �o �hr LYorkeri a- Compensation provisions of ihe lebor Code,you mus�forth- p��cc 1q081 Yorb�i, $. 232� TUSt.1I1 ,,::•..4.•.•A" � s^ with comply wi�h such provisions or Ihis pr.rmit sholl be ? deemed revoked. TF�' gK, p�, VALI�ATION CONTRACTOR Sl7iK' r]S OWI'leI' NO. LICENSED CONTRAC10R5�ECLARATION liC. I here6y aifirm that I am licensed undcr provisions of Chapter 9 A�DRESS No. 289274 yp�UATION ;j 0„�]j",, (commencing with Sr.ction 7000)of Division 3 of the Business ond LIC. �� ProFeseionz Code,and my licertse is in full{orce and effect. C�TY G�7� C�A55 �3-1 S+�.��-T"�" . H � . ��,- SO.ii. NO.OF NO OF CHECK � !�� litense N�mber 2892�4 Lit.Closs ��' SI2E , ST07'FS Z fAMIliES � ONE � .�5�7 � I •C 0 a C: //Mc. Nnv � s � O� co��oco�Presley of So CADO1e 6�30�83 OESCRIPTIO40FWORK IIld . i�r100 � , _ ,�^ AD9 � n i%Q.r V::�: �I am ezemp�undcr Sec. �ya��CUIL1tS 511-514 ALTER � FINAL / �']�� —��: B.&P.C.for this reason REVAiR � �ATE o2 ��1' �� Dafe: F%STING 9LDG. DFNAI ❑ BY A!�� $ignalUre A7i'LIUNT TEL. OWNER-BUIIDER DECLARATION PRINT Charles DeRose no. 540-0500 � I hereby aifirm ihal 1 am eKemp�fram�hr.Contrattor's License qDD2E55 96�� US Dr. T7L-S rt Beach ► law for ihe following reoson(Sr.ciion 7031.5,Businese ond Pro�esslons Code�: F4t cn ❑ 9U::D:VG r'J(1(�?i1. I, as owner of the prope�ly, or my employees wiih ADCRE55 wagns os iheir sole compensaiion,will do th�work or.d � „ � � e � , Iha structure is no�inlended or ofiered for sale(Sr.ction ��TY �'' 7044,Business and Professions Cade). MOVING TEI. � I,as owner o{Ihr.property,am e.clusively conlracting COVTRAROF NO. � e�j�j,(�� wilh Ilcensed tontrociors lo construct�he projett(Sec- qDCRE55 ' • e!�� ion 7044,B�siness and Professions Code). � �•��-= RECU!RED TOiAL SET6ACK FRO.h1 EXISi. ' CONSiRUCTION LENDING AGENCY 5[l ancK Yp'R� HNn p2CP.LINE WiDiti ► C l,� '',—F i I hereby aflirm 1ha1 Ihere is a conslruction lendint�agency for FROvf � ihe periormancr.of the work for which ihis permi�is issued P.l. �Sec.3097,Civ.C.). SIDE P.l. Lender i Name 11T1}CT1C7I'7l1 o /} P.C.Fee E .� G6 Permii Fee /7 , S� Lender's Address 1 cenify that I have rr,ad ihis opplica�ion and stote that the issuance Fee /'V. �d obove i ation' c rrect.�a�ree io comply wiih oll Couny t�ves��garo�Pee p Ordin ces nd te Iaws relafing to 6uilding construclion, Toial Fee J 7. �� ond re out rix representalives of Ihis County io enter �pon f a me iioned properly for inspettio=purpose SEE REVERSE FOR F7IPLANATOMY IANGUACE �gnar�re ol . A9e�� oie � � �s � � „ � <n „� Gl Gl V - + _ , . .. ._ �: � � c. o (� �� o 0 o n � a o o N� a o nv � � c T � �. ` ` R [) � N �' � 3 U• � C.'p �' C'` 7 n_ � �� C � S• l . �\ . _ Q. t�. - ;; c I �C � � � o � T � c .�^.c� �: `. c:' ':_ �. `1,� ;� k � - r-� • � _, r�'o' ; �� _ � J P'c: � ,�•f � c� �,., � ?' 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