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WORKERS'COMPENSATION DECLARATION � � . . y} insureborace�rifcp1teofN/orkes'�1Comfpensatonensurana" - - ��--AP-PL-ICATION FOR BU.ILDING- �PE�RMIT �� or a certified topy.tKereof(Sec 3800,Lab.C.). . � - COUNTY OF LOS ANGELES : BURDNVGAND SAFET_Y ❑ v 59CK7 72 � - -_ _.. -- Polic No �-__pany� ��'1d fl5lla�f',V� ---� � BUILDING Certified copy s heteby fumished: FOR APPLICANT TO PILL IN ADDRE55 3506 Hawkwood Road �� Certif'red mpy is filed with fhe-county-building inspec- BUILDING � fio�ilepartment. � -A��RE55� 35OC7 Hc3WKWO0� ROdCI �ocnuTv Di amond Bar � �� � � - � NEqREST /� oa,e APPi;�p�, ' an Diamond Bar Z�P ceosssT. a" �-��"'` CERTIF4CATE OF EXEMPTION FROM�WORKERS' - NO.OF eL�GS. �ASSESSOR -� COMPENSATION INSURANCE- . - SIZE OF LOr NOW ON LOT MAP BOOK PAGE PARCEL USEZONE MAP� - (This section�need not be completed if fhe permit is for one /i G�.�_��_� hundred dollars.�$100)or less.) - � � - TRACT 34�6�-Y BLOCK LOT NOZH �,/ No. '� . . . TEC - �-�- SPECIAL I tertify that in ihe perfarmance-of.the-work for which.this OWNER P NO. - ��rG� CONDITIONS 4�#, ermii is�ssued,I shall no1 em �o ❑n erson in an manner �DISTRICT .GROUP-�-TYPE FIRE PROCESSED BV 6� P p Y YP Y AODRESS 2082 Business Genter Dr, �700 corvsr. zoN�_ � � so as to become sub�ed to t5e Workers'6ompensntian Laws. - f�} �} �%%. J� �Q_� � �� � � � CIiY � 1Y��1�IlE � ZIP �271�J � �' ' � Date � Applicant � -�� �� ARCH1TfQ 01t � �� ��.TEL � �.STATISTICAL_CLASSIFICAT�ON _ APT CONPO NOTICE TO APPLICANT: If,ofter making lhis�erTificqie of ' ` -��' � � �+�/ _ a.s �' �mption, ENGwEeR Hram�:�Bassetl:.lan � :-. Ho. 7��.�=1864 : �. ap�sNo. t[�t�.�-. o�nFu uNirs� --- :�h you .shauld become su6jed ro the�Workers' n' n i- - - � � �� -� .�pensaiion�provisions of fhe Lctbor Code,,yoV r�u51{oAh � RppRESS �99�'�W�$te�'�'.�.y P�e �'Ve�YQrt��'-BeaC�� SEWER MAP� � � � � wrth mmply with such proyis�ons or ih's permit'5ha11 be � � � deemedrevoked. . - CONTRACTOR P�nderOSa HOIi1ES � TE�' H33-�L�IHO �� �gK.,� p�y, �� � VAUDATION - LICENSED CONTRACTORS DECLARRTI6N � �� �. � � � � � �� uc. � I hereb affirm that I am licerised under covisrons of Cha ter 9 aDDRE55- �Sdf172 d5 d�.7�Ve. N�_3434r'J6 y P P VALUATION (commencing with Sectio�7000)of Drvisio�h 3 of ihe Business and .' - . ���. B $ �� ! � � � � Professions Code,and m license�is.in full force�and�effect CI7Y CLASS �j6 , � � ' � SQ. T NO.OF NO.OF CHECK LicenseNurnbe� 343456 �ic:Class R size�255 63 srozies Fqmwes oNe Ponderosa Homes "�"' � $ � Contractor � �- -�Date - OESCRIPTION OF WORK ❑�am axempt unde�se�. Sl tlgl e Fami 1y P1 an 6 AX Ap° � �p/p' p ,�� � g,a q . . A�7ER ❑ DA EL !/ ��rJ'�� � 8.&P.C.�for ihis reason� REPAIR ❑ �°�"' � �'�1 . - Date: USEOF DEMOL FINAL (�'� i � EXISTING BLDG. � � gY � � r�l c�J,y� , Signature - . APPLICANT TEL PkINT� NO. � � - OWNER-BUILDER DEG6ARATION � �r�?��E��' I here6y affirm ihat I om exempt from the-Coniractpr's License qpDRE55 . Low for the following redson(Secflon 7031.5,Business and , -� - -�-� � � Q� ��L"��l Professions Cade): . � � � ,gUELDING nI, os owner of the praperty, or my employees with ADDRE55 - � -- -- -�-�- - � -wages as fheir sole compensaiion,will do the wb�k and LOCAUT�'- � - _��� � �%•� � ihe siructu�e is not intended or offered.for safe(Secfion . - � - 7044,Busirtess and Professions Code). . ,- - MY7VING TEL. ' ' a � I,as owner of ihe properfy,am exclusively coniracfing .. CONTRAC70R NO. ' ��°� � " i" � I with licensed contradors to mns{ruct the projeci.(Sec- , e,�ry r, � Yion 7044,Business and Professions Cocle). � �NDDRESS � �I J.. (�(� - REQUIREq TOTAL$ETBACK FROM EXIST CONSTRUCTION-LEN�ING AGENCY . � � Ser ancK YARo Hwv p20P.LIN wiorri � � m >,, T 5,Q0� I hereby offirm ihat there is a construction lending ogency for . : FRONT- -- y -�X�� . - - � � ihe performonze of the work tor which�.this permit�is ssued � P:L: f� � �� . � Q'� L(,�,���j(� �Sec.3097,Civ:C.). - � � Sioe� � � � - � . Ponderosa Homes P.�. �: �-= - .,%c' Lender's Name -� � � � - � . . � � $ 2082 Business Center Dr, Trvin R.�.Fees :� � �,` Pe�m��Fee ' �� �� � Lender's Address . - - � � I certify that I�have reod-ihis application ond sipte fhat the � � � Issuance Fee cb• -gf� � . ¢ above informqfion is correct.I agree fo romply witli.all Couaty Investiga+ion Fee � � ordinances an S�afe� ws relating-to boilding consfruction, � 7otal Fee a�6'3�`J.jj� � u and hereby au�ori re r'�esent fives af ihis Cpunty to enter _ . $ upon ihe abav -m � rty for inspecfibn�purposes. . � � � - � � � - " � � - a v. n , . � � �:���•J . SEE REVERSE FOR EXPLANATORY LANGIIACE _. . � . 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