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No Permit Number (4)
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 � f55-n �� 4' r�� rts �A t/� -n �^n r' � "0 V7 =09� e�i a�J �? 3 .. �.. �. . �' �� �A . ��' ' � C � —� � � � _ �°.f � � �s �� 0 e ;g � i � � � � � � b � ^ `� � I I�e' '� � � � o � ae � �Q `� � C � s � s � � � � ��g '' �_,� �. 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