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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION �
1 hereby affirm-that�l have a cerfifimte of conseni fo self �PP�LI��TI�N -FOR-�BUILDI�-NG� PfRM-I-T
insure;-or a certificate of Workers'Campensation Insurance,
o�a ce�iitied mpy thereof(Sec.3800,Lab.C:j COUNTY OF LOS ANGELES BUtLDING AND$AFETY
eou�yN F .K1 7 ��[P�pany Aetna GasuaT�y :
BUI�DING
� Certified copy-is hereby furnished. . FOR APPLICANT TO FILL IN qooRESs 35�4 HdW�4W00C)-ROdf� -
� Certified ropy is filed with the munry building inspeo- eUILDING
fion deportment. � ADDRE55 3534 Hawkwood Road . �oc,,�,N Di amond Bar
� � ' - � NEAREST �+ry/� �
Date Applicont - , CITY Dl aI11011CF BaP ZIP CROSS ST. �3y�,�G.,�,�G- � �u-�-q�'-g�^'`
CER7IFICATE OF EXEMPTION FROM WORKERS � � NO.OF BLOGS. �.455ESSOR
COMPENSATION INSURANCE SIZE OF LOT �NOW ON LOT MAP BOOK PAGE PARCEL
(This�seciion need not be completed if the permit is far one 34�6�-v � � 24 USE ZONE�- MAP - -- � ����
hundred�6ollars($100)orless.) � . TRACT � eIOCK� LOiNO. �ar; NO. _ �-
� . � TEL �$PECIAL ,�.-
I ceriify ihat in ihe performance of ihe.work�for which ihis OWNER Ponderosa Homes No.833-2180 �� CONDITiONS . � 4R,
permit is issued,I shdll noi emplay any�person in any manner � �1 �-DISTRICT GROUP�TYPE FIRE PROCESSED BY �
ADDRESS 2Q82� Business Center Drive fi���. CONST. . ZONE-� -�
so as to become subject to the Workers'Compensahon Laws j� �� �`. __� . ����,s �
CITY �..ZPVl ll2 � ZIP 92]��J . �$
Oate � � Applico�Y' '- - -, -�. ��. � STAiISTICALCLA55JFlCATION APT. CONDO. �
NQTICE TO APPLICkNT: If, after�makng ihis Cer}'ficate of /+RCHITEC70 � TEL C . - � . _ ,.�/ �
' �mption, you should 60come sub�ect�to ihe Wbrkers' � ENGNEER.; �Y�dI17�Ba$S21ll,dn �14.7:l�-�864 �CLASSNO, `� owELL.UNITS.� � �
pensqtion provisions of the Lqbor Cqde;ybu must forth- � - ����9Q WQSt@P� �:'Pl �@Wn Ol"t �2ACf1 - �� � - - � � � � � �
with comply with Such�provisions or fhis permit 5hall�be � ADDRE55. ,Y . a r . ' S�WER MAP�
deemed revoked. � � � - � TE�' gK.,/�"pG, /r� VA4IDATION
coNrRacroR POI1a2Y'OSa l{011125 No.833-2�8�
UCENSED CONiRACTORS DECLARATION� � - �� � � � � 11C: � � � .
I hereby affirm thot I am licensed under provisions of Chapfer 9 ADDRE55� Shcll@� dS a6ove � -No:343456 �-vnaunr�ora -
(commencing with Section 7000)of Division 3-of ihe Business and � � LIC. �,�,.
Professions Code.�and myJicense is in full force and�effecL CITV � CLA55 B $ f�� �d ,
SQ.FT: NO.OF NO.OF CHECK
License Num6er—343456� Lia Class � B- SIZ S70RIES FAMILIES ONE .
. . . . . � NEW � $
co�va�,o� Ponderosa Homes oa,e DESCRIPTION OF WORK
Sin le Famil Plan 364 CX AD0 ❑
�I om ezempf under Sec. � - � q�TEg � FINAL 'p �,� 1 8��
B.BP.C.for this reason � � � DATE- ���-�'T-
REPAIR
� � USE OF DEMOL
Date: � B NAL yy�p�� d`,1 8 � � �G� _
EXISTiNG BLDG. y ��P
Signature - APPLICANT TEL. � �J+�e1,C�1
OWNER-BUILDER DECLARATION � PRINT NO. �� � �
I here.by affirm that I am exempt from the Confractor's License � , ,. ,,,`j i?<),'� �
Law for the following reason($ection 7031:5,Business and ADDRESS - �
Pro4essions Code):�� . - . pRESENT (j� )(j a-�(�.
��.BUILDING . .
n I, as�owner of the property, or my employees with ADDRE55 . � - �
w6ges as fheir sole compensation,will do4he work and �OCALITV � �
_ the structure is not intended or offered for sale(Sedion � . �
7044,8usiness and Professions COde). � . MOVING� iEL �� ' - � .
� I,as�ownEr of ihe property,,am exclusively conirpciing �CONTRACTOR No. �,i i c�J�
wifh licehsed coniiactors}o consiruct�fhe project�Sec- qDDRE55 � � - -
tion 7044,Business pnd Professions Code). � � __ _ _ ��_� o � w�m � _
CONSTRUCTION LENDING AGENCY REflUIRED � TOTAL SETBACK�FROM EXIST.
$ET BACK Yf+RD HWY PROP.LINE WIDTH
I hereby.gffirm fhaf there is a consiruUion lending agericy for _ Fpgy7_.. .._ _____ . _ . .. � . _ / ., _ .,j e.r`',J�,Q(�
the perform4nce of ihe wark�for wkich fhis pe�mit is issued P.L �`+,� �� f� � � �
iSec.3097,Civ�.C.):� - ' �. � � SIDE _ ;r, ..--/- . . ... � . . - . w a 6J�1�l J Q<5
o �e�aars rvoma Ponderosa Homes P.�. � .�-� .�.� _ _ _ _ � L�4�g tt
2082 Business Center Dr, Trvin Pc Fee$ �3�'-�/ Pe�m�;Fee �'-$�'� -���
Lender's Addrass . ... . . .
I[erfify ihat I have read ihis opplication pnd stme fhat ihe � Issm<e Fee� � f c�.�"`� _.
¢ above information is mrren.I�agree to comply with.all Colunty .Irnestigo�ion Fee - -
�' ordinances and Sfate laws relating io building consiruction, � - Total Fee �'� ��, ��
and here6y uthorize representafives of this County to enter �
u -
� upon ihe a ve-m ntioRed erry for inspection purposes. -._- .-.. .- . --. .- -:---- ----—--- .-.. -. . .... . .- - . -
a i �
-� � ���'(�•^` _ SEE REVERSE FOR EXPLANATORY LANGl1AGE
Signatur f Applic nt o Agent � Date - � �B
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