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HomeMy WebLinkAbout1192A 1193A (5) - �WORKERS'COMPENSAiION DECLARATION __ - -- -� - �"� I hera6y=affirm tkor--I have a-cerrficate of-tansent ro-self Z _ _ � insura�oeacartific6teofWorker5'Compensafwnlosveorr[e, .-�-�PRLt�ATIO-N F4R- BUILDIN-G PERMIT or a ce�tified copy tHereo4(Sec.3600;�ab:C.) �pUNTY OF LQ5 ANGELES BUIL�INGAND SAPETY P�zY�9CK12723SP�mPanrAetna Ca�ualt.Y = � -� _ Ceilified eo .is hereb fuinished�.- eU1lDiNG 351�7 Hawkwo4d Road � ay_ v ,-- F4R APPL��ANT TO F1LL IN ADDRE55 (, --Certified copy�is filed with ihe tounty�building insper � ` BUILDING � � � � � �,J - �� .-�- � � � U fiOn deparimenf. - ADDRE55� 35�7 HdWkWOOtA ROad LOCAU7Y D�.alnOnd-B�)' � � NEAREST �� Dafe Applicont � CITY D1 d111011C1 BdF" z�P CROSS ST. /`- r2.-w;4a.p...r-;,l-`' { CERTIFICATE OF EXEMPTION FROM WORKERS' � - � NO.OF eLDGS. ASSeSSOR - y,,,� � � � COMPENSATION INSURANCE � SIZE OF LOT NOW ON LOT MAP BOOK . ` .PAGE PARCEL � . ,_ _ _-. .__ _-___- -(C6'ssection�need net be cemp4eted if fhe-permit-is-fororre -� �� -�� --. �- --- � �-�� �'� � .�.''.'�3-'-� � hundred dollars�($100)or less.) � � TRACT BLOCK -LOT NO. �f- NO. ��`���� . � -h�. � SPECIAL � I cerfif that in the erformance of�ihe work for which this OWNER PO�Cl2Y� NO. - lrr7�� COnloftlONS - . � Y p �i ��DISTRICT GROUP��-TYPE �FIRE- PROCESSE�BY +�d permiYis"ssued,ishall-noiemployqnypersoninanymanner qoDRE552082 Busi:ness Center br tt�Q� CON�� ZO�N_.E �� � so as(o become sub'ect fo ihe Workers'Com ensotion Laws. . / . _ . . � , . I P � - �f� . :�� ,..--^ � /�'_ _ce.z..c�s '�= c�rr Trvrne z�P 92715 � Date " APPlicant'. ' ..� � ... . . STAI'ISTICALCLASSIFICATION _.. APT. CONDO. }.e QRCHITECT OR - - TEL .. ' .. �y f P=6 NOTICE TO APPLICRNT: If, ofter"making fhis Certificate of � pNG1NEER:�' AY'dlll.�.gd sen:i n 1�19 752-1�864 CLRSSNO. ����- DWELL UNITS`�_:� � - � ' �mption, you should becohie subject��io �ihe�Workers -�� - �-. �: �- -� - - - � � ipensotion provisions of ihe i4bor code;Yo��m�s;to��n � � A�oREss:3930�:-Westerly.�P1 y �EN�pQI"t �2�Ch ' -�- SewER ti�aP- - -� � � ' � � � � �nc �omply with such�provisions or this.perrnit ShaIF be �� � � - - -.... deamedre�oked. � . - � . . � e4Nr�aerp� Ponderosa Homes �';Eo $33-�Z�B� � �sK�. . vc, ,/g�s''✓" VALiDATION � � ��LICENSED CONTRACTORS DEC�ARATION�- � � � � � � � � �� � •LIC.� � � � � I hereby affirm that I am Iicensed under provislons of Chap�er 9 AD�RESS Sd11I�.dS above � �,o:343456 - vnwanoN � � � - (commencing wiffi Section 7000)of Division 3 of ihe Business and � ���, /�:/ f� � - ' Professions Code;.and my license is in ful�force�and effeci. CITY CLA55 B $ ! � , . 343456 B si FT 6 s oa°s Fa+ni°es oNeK ' License Number ��-Lia Class POI�deY�OSI�� HOTCIES - DESCRIPTIONOFWORK NEW � Caniracior Dafe - AOD � � . .- . �� � 4`�1} �I am exempt under Sec - � �l.il 1 e Fami ly�Pl an 2234 CRX � � . . ALTER Q FINAL �j a, /� �� e��.'� B.&P.C�.for this reason � REPAIR � DATE O �� . . USEOF FINAL�,� - i-�57 ���"`� - � �Ofe' . EXISTING BLDG. DEMOL ❑ 8 !/F�2''�/��u'`�"'`�' r . Signature � � APPUCANT TEL. y . . �� �,�'.�.5��. . OWNER-BUILDER DECLARATION � �PeuvT) NO. 0 � I hereby affirm that I am exempf from ihe Coniratfor's License , � [� 7,G 4"`�G� � Lpw for the following�eason(Section 703L5,Business and .AD�RE55 Pfof955ion5 COde):� ' . � . PRESENT � - � . . � ..� . .eUILDING . . .. . . . . I; as owner of the property, or my employees with ADDRESS wogei as iheir sole compensation,wil I do ihe work and ���- , . the strudure is not infended oroffered for sale.(Section LOCALITv � -- . � �i � �i',5 F 7044,Business and 7rofessions Code). .� � MOVING TE�. - . � � I,as owner of fhe property,am ezclusively�confiacting C NTRACTOR� NO. . - €��� �" �' � with li<ensed coMractors to consirucf fhe projeci(Sec- qDDRE55� - e "'r)�i-5,Q Q tion 7044,8usiness and Professions Code). � � -REp UIRED TOTAL SETBACK FROM EXIST. � CONS7RUCTION LENDING AGENCY ' �SEY�BACK YARD HW1' pROP.LINE �NIDTH - -- � � � e:t L�j;?()�;� I hereby atfirm ihat ihere is a consiNction lending dgency for � FRONT �/ �/ � -��� - � ihe performance of the work for'.wh�ch ihis permit is issued �.L � ��`� rl �`7"" �� � �. . . Q ���[t, E{/� (Sec.3W7,Civ.C.).� . .�.. . � . . .SIDe� � r.- � . .. � . . - Ponderosa Homes P�`' `' � �`��� tender's Name � � - - - � . - � - . ; 2082 Business Center Dr Irvire Pc.Feea .�"9:�. S� Pe�m,�Fee ��''�g�? - Lender's Address . - - . I cerfify fhot I have read this opplimtion and state fhat ihe � � Issu ce Fee l C- .Sf� above information is mrrect.I agree to comply wiih all CouMy .investigation Fee pn ordinan[es ond Sfare laws relating fo building construcfion, � To��Fee +��, � and here6y aut�ori �resentaiives;of this-Counry to enter � � upon ihe ahov m nfi ned p erty for inspection�purposes. - - - � , �� . � ..�JD`- - SEE eEVERSE FOR E%PLANATORY LANCUAGE . . . � - S�gnar�re o Applican r�genf Dnfe-� - � � - � � - �s ��--- , � ' rer-, n� �— T-. e� � cn � �p g � � o ,�� =as� f� � . � Je . . ..- �� � 6 y I� � oo ° °3 � cz Q C rnn � �� � � m e�, � �. 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