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� WORKERS'COMPENSATION DECLARATION �y I here6ypffirm ihat I have q certificpTe of consenf to self -AP-PLICATI4N FOI�--�UILD�ING�-�P-ERMIT �� insure,or a certificate of�Workers'Compensation Insurance, -� - � - or a certified capy thereof(Sec.3800,:Lab.C.) - � � � 59CK�27Z3S�R� A@.tlld CdSUd�t COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olicyNo. . .. ppny .Y :: -_.- : . . . .. . ... � .. . , Certified mpy is hereby fornished. FOR APPLICANT TO NLL-IN nooREss 35Z$ HdWICW00CF ROdd � Certified copy is filed wiih the county boilding inspec- � BUILDWG � tion deportment. :. - qooae55 3528 HdwkWDOd ROdd �ocauTr Di.amond Bar � . � - �� ' NEAREST Date Applicant CITY Dl dIpOCICI BdY' ZIP CROSS ST. ��tf�{�~ � ,..��an_"--,��-z�"" � � CERTIFICATE OF EXEMPTION FROM WORKERS' - � NO.OF s�oGs. �nS5e55oe � - COMPENSATI6N INSURANCE size OF�Oi NOw ON LO7 MAP BOOK PAGE PARCE� ___ _____._., ._.. .. _.... . . _ _ . . . . . . . _ . . . (This section need not be completed�it ihe permit is for one � -OSE ZONE MAP - -Cy �� -�:-� TRACL3Q. - - BLOCK LOT NO. hundred dallars($100)or less.) � . � �?f NO. � �"-�' � � TEL �^ SPECIAL ;� I certify that in the performonce�of ihe work for which.this OWNER Ponderosa Homes No.833-2180 �(/'�1/ CONDITIONS. - i,�.. permif is issued,I shall not employ any p0rson in any manner r DISTRICT�- GROUP-TYPE FIRE PROCESSED BY � so as to become subject to the Workers'Compensptian Laws. /aDDRESS 2OHZ BUS�1 rle.S�S. 4.ECIteY�-DY��.VEE #��� CONST. zOnlE � /' s:� cirv I:Y'Vl lle zir.92715 : j� �`� � %�" �'-' $"���``� � Date � � ��Appl¢a�f� - � , � ,�� � STATISTICALCLASSIFICAT�ON APT. CONDO. C• NOTICE Tp APPLICANT: If, after making�this Certifimte of ARCHITEG,T OR, � 7EC. :. . . ervGwE�R: HY'dm Bd5S2117dC1 r+o.752-1$fi4 eiASSNo. '�� �wEu.uwrs '7"`j � -mption, you should become sub�ect 10 the Workers' _ .. .� . ,. � ipensation provisions of ihe labor Code;you�must forih- '. �:�'- � � � � - - � � � � .. �� with comply with such provisions pr this�permit 5Ball�he � �/+ookESS��� . �P. N � t e��. h SEWER MAP� . � deemedrevoked. � �� - eoNTRACTOk POYF(�2F"OSa��.HdI1125�NO833-21�8� -�eK:� PG, /°,'��- VALIDATION - -- LICENSE�CONiRACTORS DECLARATION � � - � � � � UG � � I hereby affirm that f om licensed under provisions of Chapier 9 nooRE55 same d5 dbOV@ -��No:�J4��56 VALUATION �commencing with Seciion 7000)of Division 3 of fhe Business and - - � LIC. g $ �r� �.� - -� Professlons Code,and my iicense.is in full force and effec�. CITV� C�a55 �� ,. � � 343456 g s4. No.oF No:oF cHecK _ _ , License Number - Lic.Class SIZE�26 60 STORIES FAMILIES ONE � � POI�deY�O$Z HOTIIeS -� DESCRIPTION Of WORK NEW � � - � � Coniractor �Date ApD O ❑i am exemPr��de.se�. 5i ngl e Fami 1y P1 an 6004 BX A�TER � FINAL t� . ❑ DATE,-� .-�y� d� 'F I � c�'i�l A -6.8P.C.for ihis reason � - � - aepAlR � � � � DaYe: EXISTOINGBLDG. DEMOL � �INA��i',�-��. . �4° � a ��S _ B � $iqnptur9 . . . . . APPLICANT � TEL. y � m� f(�:v� OWNER-BUILDER DECLARATION � . . PRiNi) NO. 1 hereby affirm thai I am exempt from the Coniractor's License �� � , - e�j%�,�;(��`� . law for ihe following reason(Secliorn7031.5,�8usiness and ADDRE55� . . � Professions Code): � . � . , pRESEM .� '� E%/,j.-�-��(j (-� -�BUILDING . . I � I, as awner of fhe�property, or my emplayees with ADDRESS� - �� - wages as their sole compensation,wil I do fhe work and � � � . , . .. the siructure is nof intended or offered for sale(Section LOCALITY - __. ,... . .� 7044,Business and Professions Code). � � MOVING TEL � � � � � I,as owner of}he property,om exclusively confro�ting NiRAC10R � NO. � . �. _'' '� �,�F, . wifh licensed contractors fo constru[f ihB�projecf(Sec- qDDRE55 � ' - � �fion 7044,Business ond�Professions Code). � . � � .-� �.� m �' " a,1 - REQUIRED TOtAL SETBACK FROM EXIST. CONSTRUCTION LEN�ING�AGENCY � � � SET BACK YARD HWY pROP.LINE WIDTH � . �� � �;(�.�('�,�O I hereby affirm fhat there is a construrnon lending agency for FRONT .. � - the�performance-of ihe work for which ihis permit is issued P.�.- �/�f ��'� � �"�� ► � � - �zd e`"i V C�I�� (Sec.3097,Civ.C.). � � � . -SIDE - � - - ��' �e�ders Name�nderosa Homes '` .� � � -�.s ' � 'I ,:'�t��8[„ $ 2082 Business Center Dr, Irvine P�c.Fee$ �J5`• �� 'e�m;�Fee ' �'{Gr.st� Lender's Address -. . - �� - .. - � I certif that I have read this a limrion and state that the � � Y PP fssuance Fee ,(C��S d - � above information is correct.I ogree ro comply with.pll County Investiqo�ion Pee ,/�9 ordinances ond State laws relating to building consiruttion, Tmal Fee `f'6 � • d EJ � u and hereby 6u horize r senta"ves of ihis£ounty to enter � � upon ihe abov -me '-ed 7o ry for inspection purpases. . :.--;- .---:- ---. -. -----_ .-..-- ...---. ... -..-. . .. - . � � � ���Q� SEE REVERSE FOR EXPLANATORY LANGUAGE Signafure Applim or A nt pa�¢ ' � . - - � .`'��s ����,���Csf"1 (�y o- I,_rm ryp �I, c gJ"; '.i .e-.�, -� r .-�� ^-s, n � ...-� . . .,_. � �� ��. � � g '� � O O � I �� � -` � c �n � 4 �% p T' m,.�1„� � i � .,_� � �.. . .. �' �. _ �. �9 � � � � � � � � � � � �� x O � � _ � � � i � Q � 4 `o � R� � �� �c � � � o � � � ca c�� � � � � e� :, � �' � �3 � -�,` �� � �'.� '�' � p � i n.. t� 'w � :,p (3� j z� p � f � v` p� � o Q � - �� � � �a� � eN � 1 � ,y; �� �-a ' — �- Q '�ro -�' � '� � ! �i � ' !'' € �° � �- o �' _i q� � � � s� � � ca , o r; � �y o 1, i � �: � �" ,� � n k� � ti q ^� � 3 � � � � "� � � � i � f C � r �s p � �J' ��� � tl s' �. + ��_`�_. 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