HomeMy WebLinkAboutNo Permit Number (4) � WORKERS'COMPENSATIORI DECLARATION ��� I here6y affirm thoi I haye a certificate.of consenfi to�self �insuYe,oracertifimte-of Workers'�omPensar,o�.�n5�,a��e, . APPLICATION�-FOR BU-ILDI-N-G- PERMIT or a certified_copy rhereof(Sec.3800,Lab.G) COUNTY OF LOS ANGELES._ BUILDING AND SAFETY Po,;�,,��.CK12723SPl�ompany Aetrra Casualtv - � Certified copy is hereby:furnished FOR APPLICANT TO FILL W - Bu��o�N� . 35�4 ydWkW00C� ROaC� ADDRESS � Certified copy is filed wfih the couniy.buildiog inspec- gUiLOWG ro�depa�rmeni. nooRess 3514 HdWkWOod ROdd iocnurv ��amond Bar Di amond Bar "E"REST n Date APPlicant � CITY ZIP CROSS ST.- S,'�- .d � 3 .�-�-f v"' {ERTIFICATE OF EXEMPSION FROM-WORKERS' - � � - . - - No.oF e�oGs. nssessoa r � COMPENSATION WSURANGE SIZE OF LO7 NOW ON LOT MAP BOOK PAGE PARCEL This section need not be-com leted-if ihe ermit is�for one USE ZONE MAP [,',7;ry a ( P P TRA�T34161-V BLOCK LQT NO. NO. 7 ✓ ^.�.�� hundred dollars(�100)or lew.) ,� � - �?/ � � TEL SPEGAL I certify that in the perfoemonce of the�work for wFich ihis oWNER Ponderosa Homes � No. 833-2180 - �s� � coNo�r�oNs - . i permit is issued,I shall not em plo y an y person in on y manner _ � - DISTRICT .GROIIP TYPE fIRE PROCESSED BV Ped - so as fo become sub�etf fo fhe.Workers'Compensaiion Lnws. ADDRE55 2 0 8 2 Busi ness Cen ter d}"���}�0 0 CONST. ZONE � arv : TY'Vane zip 92715 ,��1 �'� ,� 'j✓✓ �r Date � � App�icdnt - '��- � � � � . :STATIST�CALCLASSIFlCATION . / �APT. CONDO. � NOTICE TO APPLICANT: If,�.gffer mak'ng��this Certificate of �- '''��H�����^�m-�'BdSS@hl:-dfl ��`NO �rJ'2.=��64 � �� � mption, you�shbuld become subJecf.fo the W�prkers' ENGIn1EER . � CU1SS N0.- i*'''"'�y'��-- DWELL.UNIT$_J :._ -.,._ ,_. ..� ���pensation prov sions af the Lcil7or Code,yQu mUst forlh ' � A�R� 39��_�ryQStp�"�.�/ P�� �ye�rf �T"� BeS�(,`h $EWER�MAP - -- � � with comply wifh Such provisians pr this parmif shal� be � �7E�, �/�. VqLIDATION ��' deemedfevoked. . � - � � ' CONTR:4CTOR .P�naer�Sa-H0�172$ -' Np 8�3-�2�8�. ' 6K�. . �PG,/Yt -LICENSED CONTRACTORS qECIARQTION-� - - � � � � � - ��i�, - - � I hereby affirm ihof I�am Iicensed under provisitlns.of Chapter9 -AD�&E55 same as�above � .No:343456 VALUATION (commencing with Section 7000)of Divisio/i 3 af the�Business and - �� Lic � Professions Code,crnd my license is�in full force and effect.� � Ciir ,� . C�ASS B $ ��� �''K"� ► ' S NO.OF NO.OF CHECK LicenseNumber 343456 �;�.-L�ass .Li� � � s��00/639 srozies FnMiues oNe NEW $ ' P�nde�^Q$a H�me$ ' - DESCRIPTION OF WORK ' Coniractor Date - � ❑�am exemP���de�se�. Si ngl e Fami 1y Pl an 220Q AX Ao° ❑ . ALTER �- FINAL � ,J � B.&P.C.for ihis reason DATE � � r�g' �"� � ���+ REPAIR � a . . Date: E%ISTOING BLDG. pFJyiOL � FINAL y-s��. 9{e � �' '"L 1 APPLICANT TEL. gY �/ Signafure� � � `� . - PRINT � NO. � � �`�?Z.�� � OWNER-BUILDER DECCARATION � . I hereby affirm ihot I am exempt from fhe Coniractor's License �- � ► c i v'(,1(7? Law for ihe following reason_(Section 7031,5, Businegs and A�DRESS � . � � Professions Code): � � . - � PRE ENT �)�,�`�/{--�j(L ^ - . . �BUIL�ING � . .. . . . . .____._... • � 1,as owner of fhe property, or my employees with aoogeSS- - -�---� _ wages as}heir iole compL>nsation,will do-the work and --� � . . . .- the sfructore is not intended or offe�ed for sale�(Sectian LOCALITY . � � 7044,Business and Professions Code). .� MOVING TEL . , �' � �t�A � I,as owner of the property,am exdusively confraUing CONTRACTOR NO. with licensed�contracfors to consirud the projecf(Sec- pDDRE55 - � �� ° " � r� � �tion 704a,Business and�Professions Code), - - � �CONSTRUCiION LENDING AGENCY � �SEQBtiCD � iOTAPROP ACN�FeOM y,�ioiA ' � ( �5��O O YARD HWY I here6y offirm ihat fhere is q construction-�lend'ng agency for - FRONT f ,y � � - ihe performonce of the work for which this pe�mit is��issued p:L�� � ��-F� G< ���f �f"'� � � � %J:;r'Q(1 ti (Sec.-3097,Civ.-C.). � . � . SIDE > Q I,� l'�*�j�6 . - Ponderosa Homes P` �' �`�� 'f�f' � " Lender's Name� � . � - - .. - - - . 2Q82 Busi ness Cntr Dr, Trvi ne P.c.Fee s =-3`,�.�-�� Pe�m��Faa G�5�/ ��'� • lender's Address � � - ' � � I certify that I hove read ihis applicafian ond sfate ihat the � Issu ce Fee �U..�� � � x above information is correct.I agree to comply wiih.all Gounry � Gvesf�gar�oo Fee an �/ g ordinances and State lows relating ro building consinuction; � � ioml Pee .7 J�^�� � u and he�eby-uthorize7epresent tives of this County to enter - s � upon�he ah ive-m nhbned p��erty for inspec�ion purposes. � . . - � - � - . - -- - -��� '� ..e (� � �Iti..���'' ^ , �- � �Cg"".p . �SEE REVERSE FOR EXPLANATORY LANGUAGE . � Sgnature fA�nfarA9ent ... .. -�-.—Dote ' � . . .. . . ..-"----�---- ---�--�--�-�-- — �5 � `,A „�� � : S � � � "�''`° 'w z�ro a� c „ m � u �•-� o�y,, a "� �� € g� � � p ay �."'� s tJ`� � �h�v o 3 °fl ofii��h o�4` �v, �� �%� : I i , I � 6 � � � o� �' ° �,� m'� � c.-, no ��` «� y-r � � w � `c � 0. � o 0 1 � � ; � c ,a'y °' �^c' c.`''`'`"�o� ro n u� o � � h"; � ° ° e� w s. 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