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HomeMy WebLinkAboutNo Permit Number _ _ _ _ ,'� WORKERS'COMPENSATION DECLARATION �� I hereby�offirm ihat I have a cer�ificate�of.consent to=e�f �-- APP�LIEATIt3-N��- FOR���BU-1LD1--N_G--�P�ERMIT insure,or a certificate of Workers'Compensafion Insuronce, � - or a certitied copy thereof(Sec.3800,La6.C.) . COUNTY OF LO$ANGELES BUILDING AND SAFETY PolicyNo.`�gCK12723 c�a„Y Aetna Cas.ualtY � ����- � - � - - � � - - - � Certitied co is hereb furnished. . . BUILDING _ py y FOR APPLICANT TO FILL IN aooRess --3525 HdWkW00d ROdd _ � Certified copy is filed with ihe county building inspec- BUILDING . - - ��o�aePa„men�. AooRess 3525 Hawkwood Road �o�A��TY Di amond Bar � ' � n � �.�J b n�� NEAREST /} /� ' Dafe� Applicant .� CtTY ''UlC�I7��nu �UHY'� � ZIP _ CRO555T. (�..i:t._ ...L..mc.-�. ,..�-f-L-�c-�s—'� CERTIFICATE OF EX�MPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR � G � COMPENSATION INSURANCE - SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL This section�need not be�com leted if ihe ermit is for one - --� - - �-- -b5E ZONE----MAP��-�-� �� - p�R -�- - hundred dollors($100)or�ess.j . . P, TeacT 341-61-U s�ocK �ar No8� ,�� ._ No. �-y� � �� ' � TEL. 4s SPEpAL $-. I cerfify ihot in ihe performon[e of ihe work for which this �WN�RPonder�sa H ES NO. - ���� CONDITIONS � _ SA. permif is issued,I.shall nof employ any person in any manner p -�DISTRICT- GROIJP TYPE PIRE PROCESSED BY � so as to becOme subject ro the Workers'COmpensafion LqWS. .4DDRE55�2OOZ BUS�YIeSS Center Dri ve ���� CONST,.,..�--- ZO,JVE-� 6�A . � .. p �7 C C� .���� � �✓� :�e�rr,<._.. €�t . qTY AI"V�I�ie � ZIP . �2(�J� -"`� �v Date - - - Applicanf� � � , � STA715TICAL CLAS$IFlCATION. APT. CONDO. ,Ym :4RCHITECT OR TEi {,g NOTICE TO APPLICANT If pfter�mok ng flils Certificpte ot � � ENGINEER.� X>l0 - CL(iS5 NO `��"� �WELL UN�TS�� � � � nption, you.shbuld 6etome su6�eci-�to�the Workers- � ��.� � �, npen'spfion provi5inns of fhe Lqbor 6ode,you musf forih-� _ {�ppRESS-�� gQ ���$"te�" ��'P (�E���'Q}^'� ��aCh ' SEWER MqP ����� - �. � , ry with comply�with such provisions or�ihis.permif.�shalb be �� � �� � - - ,m deemed�e�oked. coN,eacroaPo dero5a Homes. ivo.833-2180 BK.�' P�• �'�� �^��°^Ti°" � 410ENSED CONTRACTORS DECLARATION � � � - � � � � � �� -uC. � I hereby affirm�hdt I am licensed under provisions of Chopter 9 qoDRE55 Sdf172 as� above� �No:343456 -- ,,,,�ua,�or,�� (commencing wifh Section 7000)of Divisio�5 3 of the Business and � � � � � LIC. � Professions Code,and my license is in foll force pnd effect CITY � � CLA55 B $ ���,� l��a'� , 343456 B si°z�200 69 s"roa°s F Mi°Es `o EK License Num6er lic.Class , PQrjde�"0$a HQmQ$ �ESCRIPTION OF WORK NEW � $ Contratror - Date - � ❑i am exempr��de�se�. Si ngl e Fami:l y P1 an 2.200 BRX Aoo ❑ . ALTER � FINAL y p B.6P.C.fo�this reason � � REPAIR ❑ DATE �oc�fb� � 4 � L?�� USE OF � �Date: DEMOL � FINA,L{ . EXISTING BLDG. ❑ � (-}a � " �G�I APPLICANT TEL. BYL�'�' Signo}ure - � � . �. . OWNER-BUILDER DECLARA710N �. PRINT) NO. , � t-- t m �2 2�O I hereby affirm ihat I am exempt from the Contractor's License � I,pw fm ihe following reason(Section 7031.5,Business and ADDRE55 --�,, - � - � - a '� �r �,�,_Q u Professians Code): � � pRESENi- - �-t � �BUILDING . . . . . . (��„`�(.�-�;�J. ,' I- I, as owner of the�property, or my employeas wifh ADDRE55� - - wages as their sole�compensation,will do ihe work and . � . . ' ihe sirutture is nof iniended or offered for sale(Section ��ALITY ._ . . ' 7044,Business and Professions Cod�). � MOViNG ie�. � _ . _���.:'. . �'� � 9��f� � I,as owner of fhe properiy,am exclusively confraciing CONTRACTOR NO. - � � �v with licensed contractors ro consrruct the project.(Seo- +:° � � '�.� �tion 7044,Business and�Professions Code). . /+ookess �REQUIRED TOTAL SETBACK FROM EXIST. � ( � �-J�,O O CONSTRUC710N LENDWG AGENCY� - � sEr aqcK VnRo HWV PROP.lME wIDTH I hereby a$irm tbbt there is p-consfruc�ion lending agenry for PRON7 ,/. � .�` . . / , � . -� � �.-c r?�`�t�x ihe performance ofihe work for which ihis permit is issued -P.L: °f'- �!- `�' . - � (Sec.3097,Civ.C.): � - . � � SIDE � ' � P:�: �.�-> �� � r��v CI �!,2�-�8 4 m Ponderosa Homes - v Lender'sName � . . --- . -� � $ 2082 Busi ness Center Dr Trvi ne P:c.Fee s :����.�� Pe�m��Fee ,1`�/-�� Lender's Address .. - . � , . � I certify thot V have read this applicotion�and sta}e ihat ihe - Issuance Fee /d•-�� � a above information is correci.I agree to comply with all County Imestigation Pee - g ordinances�ond State laws relating to bulldinq consiruction, - � -� To�al Fee .�"�'S'��•. !J'"tZ �i and hereby a.ihoriz rgpresenfafives of this County to enter� � opon the abo e- enNoned peNy for inspection purposes. � - �� � � � � - - � � � Q ?� � ` `"� .�� � SEE REVERSE FOR EXPLANAiORV LANGUAGE . 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