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_ WORKERS'COMPENSATION DECLARATION _ �j I hereby affirm�ihat I ha�a a�a,,�f��a,e o,consent fo 5e�f _:qpp���qTIQ-N_ FOR- BU1LD-I-N�G Pf--RMIT �zL ii msure;or a certificate-of-VJorke�s Compensation-Insurpnce, � . - _.. _. . . .. . . . .._. .. .. _ . . or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY PolicyN`�gCK727235P�mpany Aetna Ca�sualty .-� . .. . .- . � . . . . . � --... . ... . . . - �_ Certified eopy is hereby furnished. FOR APPLICANT TO FILL IN--- qo�2Ess 354'Z HdWkW00C� fZOdC� � Certified copy is filed wiih ihe county building inspec- BUILDING f�d�dePa��me�r. aooRess 3542 Hawkwond Road LOCALITY Di dmond Bar . . . . �� NEAREST �p f:�.2�,/-a�c",. Date Applicant - � � CITY � DldI11011CI-BdY' ZIP CROSSST. �f[w-c- �,-u-:c .'C- CERTIFICATE OF EXEMPTION-FROM WORkERS' � - � . � �� No.oF a�oGS. ASse550R � ` - � COMPENSATION WSURANCE SIZE OF LOT NOW ON LOT nna.P sOOK PAGe PaRCEI _ .__—- ____ _._. _. Thls seaion need not 6e mm leted if the erm�t is for one - USE ZONE MHP� c p a TRA�T34161-V s�o�K �oT No. 23 � No. �'�`>'3,3 hundred dollars($100)or less.). � . , � TEL. � � SPECIAL . � I certify that in ihe performpnce of ihe work far.which fhis �WNER Ponderosa� Homes� No.833-2180 . I�/'� CONDITIONS � ermif is issuzd,1 shall not em lo an ersan in an manner DISTRICT .GROUP TVPE FIRE PROCESSED BV � P P Y YP Y A�DRESS 2OQiZ BUS1IlESS Center Drive #lOQ . �oNs�s Zor,�, so as to become subjeci to fhe Workers'Compensation Laws. . �r/ � ---' � � nN Irvi ne z�P 92715 f .t°.� ��` /.� � �:,.�r�<,.� Date � � � � Appl¢anh '� S7A7ISTICALCLA551FICAT�ON . �APT. CON�O. 6��^ ARCHITECTOR TEL ,. �. ��b NOTICE iD APPLICANT: If, aker�makm �ihis Certifcate'of . /��� � � �-�� . 9� FNGINE�R; ��� � NO. - -� CLMSS NO `� - DWELL.WNITS� � � mptiqn, you should become subject'�ao the�Workers' � � p � �. - � ipensotion provisions of the�lqbor Code;ypu musi forfh � qppRES$���`���0 �eStAY��x,P�y {��W�70Y't BGaC{l� SEWER MAP � � - - � , . s� with comply with�such.provisions or ihis permit shalF be � � � deemed revoked. � � � � � eoNrRncTOQ Ponderosa Nomes ��.No,833 218Q eK�..� ac, /�t4r,+'' � VALIDATION LICENSEDCONTRACTORS-DECLARATION � � �- �� - - � �� � �iIC -� � � I herehy affirm'thot I am licensed under provisions of Chapler9 ADDRESS same 85 above ��No..343456 - vnwnr�or, (commencing wifh Sec}ion 7000)of Divisio�3 of the Business and ��- LIC. � - Professions Code,and my license is in full farce and effect. ciiv rus5 B - � p��^��� �� ► - 3�J34�JG . B . � 5¢E� 70RIOE5 AMILIES CONEK License Number Lic.Cltiss POI�IdEP'OSa hO�IIeS DESCRIPTIONOFWORK NEW � $ ' � Confractor Date ❑I am exempt under Sec. � -� � Sl 11 1 e�Fami 1y P�1 an 2200 AX ADD ❑� � ,�i t S..C A. . . AL7ER ❑ DA EL d � .J"'/� �o s a o�,'� � B.&P.C.4or ihis reason - REPAIR ❑ �Date: USEOF DEMOL FINA I �i7 G�.2�� - ExISTING BLDG. � gY������,.�p,,�� . Signatura � APPLICANT TEI. ���,������ - OWNER-BUILDER DECLARATION - � �� PRiNT) NO. ". I hereby affirm fhaf I am exempt from the Contractor's License , �'{,L u��'�jl- Law for ihe following reason(Section 7b31.5, Business and A�DRESS - �-- ' � - Professions Code): � �PRESENT ��BUILDING. . . n I, as owner of the properry, or my employees�with ADDReSS - . � � wages as their�sole mmpensation,vrill do ihe work and � � .. . � . � - � the�siructure is not intended or.affered for sale(Section tOCaniv - . - -�- _'��1 �,� A 7044,Business and Professions Code). , � - �. MOVING TEL '� , � � � I,.as.owner of the property,am ex[Iu;ively coniraciing �CONTRACTOR NO. �' m �' `� "'� � wifh licensed confradorrto�construd ihe projed(Ser ADDRES$ - - - � . -. � { 'J J[,C t�. � ,fion7044,Business and Professions�Code). � . . - . . CONSTRUCTION LENDWG AGENCY � �SET�BACK �ARD HWV TOTAPROP.pLNEFROM yyIDTH � - � ' �` `� ��-�G U�� I here6y affirm fhat there is a ronstruction lending agency far . ..FRONT / � - the performance of ihe woFk for which ihis permit�is issued �P.L. /��� � ���. ��� , . (J,7 r�Q—fj�l . ' ZSec.3097,Civ._C.). - � .51DE � - ' � Ponderosa.Homes P� �� --� '�°' '`-�' Lender's Name � � . . - , . - $ Lender'sAddress?082 Busines�s Center br, Irvi�n. �.P.�.FaeS� .?'�•���� Pe�muFee -^'"i ,�„Srl� - ..�. , , > I<ertify ihat I have read this bpplication and stote ihot the � � � Issuance Fee IO...�`'� ¢ p6ove information�is correct.I agree ta comply withall County .Investigarion Fee � - � ordinances and State laws relating to-6oilding consfruction, - - Total Fee ,j 7�_C`"� � � and hereby auf orize represenfafives of this Coun}y to-enter � upon ihe above me io , prop rty for inspection purposes. . - - � t n � . _ � ' �-���'^ SEE�REVERSE iOR EXPLANATORV LANGUAGE . . 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