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1186A 1187A
' WOkKERS'COMPENSATION DECLARATION - - �p I hereby pffirm-thot I have a certificate�of�consent to se�f � .qpp��CATtON FOR__B-U�ILDIN-G--P-fRMI-T-- s insore,or a certificate of�N�orkers'Compensation Insuoance, - - . or a certified copy ihereof(Set.3800,Lab.C.) � � � � - Poi;�Y�9CK12723SP�mPa�Y Ae.tna Cd5Ua1 ty COUNTY OF LOS ANGELES BUILDING AND SAPETY ❑ av' v FOR APPLICANT TO FILL IN B11D1NG 3520 Hawkwood Road Certified m is hereb furnished.�-- ADDRE55 ❑ Certified mpy is filed with iKe�coumy�6uilding inspeo- gUILDING - riondepo�rrne�f. Qooeess 3520 HdwkW00d ROdd �o�.��TY Diamond Bar - - �� � NEAREST Date Appiicant ciTv D1d111011d BdP ZiP CROssST. �� �,� ���L>—<r-' CERTIFICATE OF EXEMPTION FROM WORKERS' � . - � - NO.OF 6LOG5. ASSESSOR COMPENSATION-INSURANCE SIZE�OF LOT NOW ON LOT MAP BOOK PAGE PARCEL � (This section need not be�completed-if�ihe permit is for one � � . USe zoNe MAP �..,-y�r)�4�+�� hundred dollqrs($100)or less.) � , - iRACT34��� � gtOCK �LOT NO.Z6 � / NO. f 1 � I certify fhpt in the.performance of�the�work for which this O�NNER Ponde�rosa Homes �No�.833LL2�O� ���� CONDITIONS � � permit is is5ued,I shall not employ any person in any manner DISTRICT .GROUP� 7VPE F�RE- PROCESSED BY � � so as to become subject to the Workers'ComPenSption Laws. ADDRE55 ZQHZ BUSI�YIASS Cen�er Dr� '���� CONS]'� _�E d� . 1� ,�i'"i � l.�� „�s.r.r_�: €� c�rY . Trvine =�p 92715 — ' � Date � Appliwnf -� '� :- : � � -� � -STPdISTICALCLAS5IFICATION API. CONDO. � ARCHITECT OR " • ��.TE� NOTICE TO APPLICANT; If, af�er msakng-ihis Carti�icate of �. ENGiid�ER f�r��p �dSSEpld{1 ' ..'n�p.]�J2-�$(4 - � .' '` � �.y � . . �� 'n tion, I .. . �. . . . Ctp$S.IJO. C'����'. DWELL.UN175 - p yau�should besome sub'ect'10 the Workar5' ��. .:, ` � ----- --- �. npensqtion provisions of ihe La6or Code,you m��,+o�rh - ,,poRE�s 3990:�Westerly Pl, NEWpOY����BEaC�, - SEWER MAP . � with comply with such provisians or this permit Shall be -- � TEL, -- deemed revoked � � � , CONTRACTORPOCIC�@Y'0$'$�f{Q�TI@$�� �- N�. �g33-Z�Ba�.� ' BK�. . M'', VALIDATION �LICENSED CONTRACTORS-DECLARAiION - ��� �� � - LIC. � , I here6y affirm ihat I am licensed under provisions of Chapfer 9 � ADDRE55� SdCfl@ dS dbOV2 - �NO.- 34.3q'S6� �VALUATION . (commencing with Section�00�)of Divisior5 3 of ihe Business and . � �ic. d . � � Profess ons Code,and my license is in fiull force and etfecf. � CiTY - � � � CL45S B � O u�� � ' 343456 B s�T31 639 S oR°s F MIL�IES `oNEK � . License Number Lia Class '' � P�n(�ep`�Sa H�me$ - DESCRIPTIONOFWORK � NEW � $ ' � Coniracto� � Date ADD � - ❑i a,�,aXempr��ae,se�. Pl an 6 CX Si ngl e Family A«R � FINAL `�[ a DATE ��� �/ �:1 7 �S,O A ._ 8.&P.C,for this reason� . � REPAIa . ' � Date; USE OF DEMOL ❑ BINAL,/`��L,'e j?o o e a�� EXISTING 9LDG. � Y U i �. � �Signafure � - � .. APPUCANT TEL. �-..� � PRINT) NO. � �v )C,J�I� OWNER-BUILDER DECLARATION I hereby affirm thai I am exempt from ihe CoMracto✓s License �- . ► rp 5`1�;�(�? Low for fhe followiog reasan(Section 7031.5,Business ancl FlDDRESS . PfOf05510f13 COCIB�: - -- .. PRESENT - � � �3'� �(�a„g�} . � � - . . - . . BUILDING -_.. - .. -._.... _ . __--.- ___ _,_ —___. _:- I, as owner of the-prnperty,_or-my-employees with - ADDRE55- � �- ---- --` -�-- - . � wages as iheir sole compensation,will doihe wbrk a.nd �� �� � . � � � � � - - ihe siructure is not intended or offered foi sole(Section LOCALITY � . -� , ' � 7044,Businessnnd Professions.Cede). - � MOVING TEL � � �3'� '� �']�1� � I,os owner of rhe.property,am exclusively comracting ��CO TknCTOR - No. � � . � �with litensed coniracfors fo consYruct the�projecf(Sec- qDDRESS- -� �� � � m �� tion 7044,Busmess and Professions Code).�� � - . � �REQUIRED� TOTAL SETBACK FROM EXIST. ` � 5 O jO(� CONSTRUCTION LEN6ING AGENCY � � SET encK YARD hiWV Nrtop.LiivE WIoiH - � � ._.. .._ � '•� �..�;. I hereliy affirm thdt there is a construction Iending pgency for � FRaNi- d � �� . � ���� �_c the performance of fhe work�for which this-permit is issued =-P-�. .�`� ���� ,�� �i�� z "�� ` tj n�' t5ec.3097,Ciy._G).. . � . �.. .__. . . -SIDE / . .- �. . . . . .. Ponderosa Homes P� � /F ��� G 1,21�--g 1.t � lender's Name� .. . .� .. . - . . . . . . . , . � 2082 Business Center Dr, Irvin P.C.Feea �.��1.:'s� �,r`1,�' s' Lender's Address � Permit Fee �� . . � � . _. . . . , . . . I tertify ihat I have read}his appficotion qnd�siqte fhpt the � � Issuance Fae r'`C�<:i� � ¢ above information is corre��.I agree to comply-with.all County �Investigatio�Fee - g ordinances and�Stote-laws relafing To-�-buildinq constroction, � -- � To�oi Fee ��,�,l�� � and hereby a thorize r;presentqtives of lhis County to-enter _ � _ $ upon ihe qbo e-me ioned pr rty for-inspectiort porposes ., � - � � � � � - - ��-' � � � � �j �r �- � ' ^-�(3'��� . - _SEE REVERSE FOR EXPLANpTORY LANGUAG6 In Signature� Applica or enf ' � ' Date� . �5 :� . v�-— �n N `°' L�p.'-� 6� y b.����� ca 9� t„ !n C„t�i w `� .� � i��'-_...� ,.�. � ...� I A . , i � � i� v.s...d � � ����*��'�q^� : � '� w� 9 "i��.�yc ,�� � �.'s v� '� �� � o; �, � .�, a o�.o '�.'� 3 0� m a c v� �,°, � � �s�s ��a �U w �.�n c� E., v � �-� ea , � a C " �s. � `:.. ao � � .���� my°'� �O m.-� u�i� q " �,� a � o �, k � � , � c »� w w� �o•"��� � o cu y,o'� � �, � � T,e�� d � u � . � � I � � � " "y�''G.� rn o�n� � r'�:�_� o a'`�.`� 3"� p-.�� a� � ���c, � . ei , t� : � _ -i � �V� � `'�� '� �' � � v �' m � �^� �`.,>� � � n�, �� F, ��', i : � ` . � � � �����.� �w r`�a � ��'t� � � ' � ys `� �.`' s �_ � � � � � � .- ' � ��.�o � '� ,� � w .p ca - a �+ � �� ; �. e � � : � � �-� `� . � C o ��'i� � a �' ��� �� ��� � °� �,� " c�_ � � � i � � �� � � � ', r i � v � �� `�,^,� �0°����a' � a 3��,� � � � � '"" � ,. a�' � I � � f �� � � ��� � . � d � � �;�.. � '° � cs > �� ° � � � �: � ��- f �, � ' � � � ( f � r �, ; C' . o, �, ���`� � � � s � i� €, � �, � _� � � ! � ' � � � � i � � 4 � _ � �v v'.'� � w� � o�i a��. � � s ' �, �a ; � . � � i � i _ � � �� � � � m �� ' �' ° d�,s a�.�' a a �' � �^ � � �� c"�z � " ` ''� � 'y I �� � �� 1 �. � � . 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