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No Permit Number (4)
WORKERS'COMPENSATION�ECLARATION � � � �.y I hereby affirm�fliat I hove q certificate oF consent to self ��pp`���TOON --FQR- -�BUI�LDI-N-G--�-PE-RMIT � insure,_or a cerNfimte af Workers'Compensotion Insurance, � �-�� or a cert�fed copy thereof(Sec.3eo0,Lab.C.) COUNFY OF LOS ANGELES BUILDING AND SAFETY PolicyNo59CK127235d'd�;Pa�Y Aetna Casual.tv� -�--- �� � - -- - - �� Certified co 's hereb fumished.- BUIIDING ❑ PY' Y - --- -�o�-aPPu�,an��ro FiE�itv- _ _ AooRess 3533 Hawkwood Road � Certified copy is filed wifh ihe counfy building inspec- gUILDING � � do�dapar�me�i. nooaess 353- NdWkW00d ROdd �ocaurr (?' .... . � . .. . . . . � NEAREST t) Date � ApplicaM . CITV Dl d177011d��Bd}� ZIP CROSS ST. � ,�%,� .,��...,�„�-� � �CERTIKICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR � COMPENSATION INSURANCE� 9ZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This secfion need nof be completed if the permit ig for one � USEZONE - MAP . - hundred dollars�$,ao�a,�e�5.�- . � TRA�T 34161-V B�ocK �oT No. 81 . �Q�.. . No. -'��.-�.�3.� . .� .TEL. ��l SPECIAI �., I tertify thof in ihe performaqce of the work foF which this �WNER Ponderosa Homes ,vo:833-2180 ���� CONDI710N5 __ y3, ermif is issued,I shall not em lo an y .0 DISTRKT- .GROOP TYPE -- FlRE PROCESSE�BY � p . p y y person in an manner qDDRE55�082 Bu�si ness C2.ht2F" Dri ve tt��� CONST ZO E. � �b so as to become subjeci to fhe Workars'Compensafion Laws. , . � � , � �� � �� � c�rY Trvine Z�P 92715 " ' Date - Appl mnt� ' . � . . . STATISTICAL CLASSIFICATION. � �APT. CONDO. � � NOTICE 70 APPLICANT: If, after making Yhis Certifieate of , . a�4RCHITECT 0R, �� rEL . . . � , - E_� mp�ien, you should become suh�ect io rha Workers' � �NE R. H1"dTII 6dSS21�7 d Na �52—�864 c�n55 No. �� oweu.uNirs�� - � ipensaiion;provisi.ons of the��Lobor.Code,you mUst forih- ' ADURESS���.3��JQ���WQSt2i"�y:P�� iYeW470�f t'�eaCh -� $EWEkMAP� � -'- � � � �� � viith mmply with such provisions or this permit 5hall he� - � - . � � � deemedrevoked. coNr�tacTpe . POIldOY`OSd H011125 tiEo.833-$�8O eK.�'V' PG, �� VAIIDATION �' �LICENSED CONTRACTORS DECLARATION - � -� - � � � .��c. � � - - � I hereby affirm that I am(icensed�under provisions of Chapter9 � AD�RE55 Z082 BUS111ESS.C.�1tY� �NO:3434rJ6 VA[UATIDN-� �- - � (commencing with Section 7000}of Di isioh 3 of ihe Businessand � � - llC. - � Professions Code,and my license is n.fulf force and effect CITY �T Y` � �5 CLA55 B $ .+'�L��� ,A"/`� , � � SQ.F�- � O.OF NO.OF CHfIX License Number 343456 �ic Class B srze 255 6 �rORIES Fnnnwes oNe . . _. � NEW � S ConiractOr Ponderosa �Homes pa�e ' . DESCRIPTION OF WORK � � Si n 1 e Fami l Pl an 6 BRX AD° ❑ D��1 1 9,b N �I am exempf under Sec � 9 y ALTER �� FINAL �r �J� B.&P.C.for this reason REPnIe ❑ DATE d' r+�� �7 �.� � m ��� . � i USE OF Date: EXISTING BLDG. DEMOL ❑ By'4�_��� I fl v�.�n�:�.1 - - Signatore � APPLICANT TEL. t� OWNER-BUILDER DECLARATION PRINi Np, T �.: �:S�,+�,c I hereby affirm thaf I am exempt from ihe Cantractor'a License � tqw for ihe following re4son(Section 7031.5, Business and ADDRESS -- - -� � --� . � j L.�w�4 Profe55ion5 Code): - . . � PRESENT � � � - �BUILDING . . � I, as owner of ihe property, or my-SmplOyees wiih ADDRE55 � � � � - � wages as iheir sole compepsatian,wil I do the work and - . � � . � . ihe structure is not infended or offered for sale(Section LOCALITY - � . 7044,Business and Professions Code). � MOVING TEL. - � . � � I,ps owner of ihe properfy,om exclusively confracting CONTRACTOR NO. - �_ � ��� � Q.�� � wifh li<ensed contrqdors to mnsfroct ihe pr8ject(Sec- qDDRESS - � � #,�+ w � c m '� Yion 7044.Business and Professions Cade). � � .REQUfRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LEN�ING AGENCY -- SET�BACK YARD HWV PROP.IINE W�DTH I i t`J S�G O I hereby affirm}ho�ihere is atons�ructioo-lending agency for FRONT ,�,� � the performance of ihe work for which ihis permit is issued p;L .��� �! �''� ,�it��' ► . , 4,c_,r G �n� ,.:(;vo (Sec.3097,Civ.C.). � � � � SIDE � � � _ .... . . . . ` - . Ponderosa Homes P` � ' �°�£ 0 1 �t -~8 4 Lender's Name - � 2082 Business Center Dr Irvis�e Pc.Fee$ .�„Z-�. �� Pe�m,�Fee ���"�'�s� - Lender's Address e � � � I certify tMat I have read ihis applicqtion ond stote that the� Issuance Fee j0, �A � Q above information is corred.I ogree ro comply wifh oll Counry Invesrigotion Fee . '� ordinances and Stata laws relating fo building construction, � � -- �y',1f/' Q� - -� - . 7 dnd hereby aut orize ,resentatives of ihis County to enter � Total Fee ti, x upon the abav.�men d. ro t for ins ecfion ur osas. � � . - � � . . P Y P ( P P � � �. �1 .. . . . � - . . � �`^� J�' . 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