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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION UECLAKATION � � � I hereby affrm ihat I have a cerhfimie of consent to self . APP-�1CATIQ,N FOI�--B�UILDING PE.RMIT msu:e,ora ceniicale of Workers'Compensplion Insurance, �---� or a tertified c6py thereof(Sec.3800,Lab.C:) � - - - ocyr�9���2�Z3SP�mpony A2t11d Cd5L1a�tV — C�UNTY OP LOS ANGELES _._ BUILDING AND SAFETY Certified copy is here6y furnished. FOR APPLICAN7 TO FILL IN nooaE55 ��3q 3 HdW�CW00ij ROdCi � � Cernfied copy is filed with the coumy building inspec- sWlow� Di amond Bar no�ae�.fine�,. AooRess 3543 Hawkwood Road �oca;urv NEAREST Date Appliwni � . _ CITY �1d�110r1d-�d)" ZIP .CROSS.ST. ���'�C-- t.-Y-a=-� - � -^�22`i-*-�'="'� CERTIFICATE OF EXEMPTION FROM WORKERS' � - � NO.OF BLDGS �ASSESSOR � +f . �COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT . MAP BOQK PAGE PARCEL (This section need not be completed if the�permit is for one � 3l}161-V 8'L -- ti75EZONE� MAP� � -y .,_�-.. � hundred dollars($100)or�e5s.� . �.� ' TRACT BLOCK L�T NO. �°-J- NO. _ ��`�'1'.�� i : . . . . . . - -- TEL: � � SPECIAL - �� I<ertify iFm in the performance of t6e work for which this OWNER p0i1d21"OSd �"�Otl1�S N0.833-z�8�.�� '..d��'� EONDIilONS. � &�, i permi}is issued,I.shall not employ.any person in any manner �C1ISTRICT .GROUP TYPE -FIRE PROCESSED BY � so as to become svbject ro the Workers'Compensation Laws. ADDRESS 2OHZ BUS1I1255 C2Ylt2P DY'l�Ve #�Q� CONST.�� �ZONE � . . - . . � f,IJ" �''� � ��� ,(��.z.;s.a�� - P.� aTr I rvi ne Z1P 92715 ' � pafe '„��App�icant- '� � �- STATISTICALCLASSIFICATION APT: CONDO. . � P.RCF{ITfCT�OR ' ' ' ' TEL NOTICE�TO APPLICANT: If, after�.mpking tN.is�erirficate of eNGiNEE&�: AI"dfi�fl��Bd$S@�'ITall Hp.752-1864 CL({S5No. ���'f RWELL,IJNITS����/ � nptidn, you shauld 6ecome subject�to the Workers� � I�1 .� . 7� _ �-. ��� npensofion provisions of fhe Lqbo�Code�,.you must 4orth-. �-. RDDRESS���9O WeStEY��y�:r�� N��p�rt BeaCh '� �SEWER MAP�� - . - "� with camply with such provisions er this permit shalP be -� � �� � -� - � � deemed revoked. � � - � � � CONTRAC70k P011�C�2Y'OSd �HQCI]@S i�0 �33-2�18� ����� ?��, �'�'� � - �+4��DATION LICENSED CONTRACTORS DECLARATION� ��� ��- � - �tiC. � - I hereby affirm thot I am licensed under provisions of Chapter 9 ADDRES5 � d5 b0 e �- No.343456 �vaivanoN � (commencing with Section 7000)of Divisio�h 3 of ihe Business and . � � LIC - Professions Code,and my iicense is in full force and effeci. CITV CLA55 g $ �� �� ► " SQ. T NO.OF NO.OF - CHECK License Number 343456 �ic:Class B sizei 994 60 STORIES FAMILIES ' oNe s . COnifaCior POYIdEI'OSa HOITIeS Date' DESCRIpfION OF WORK NEW � ❑i am exemPf��de.se�. Si ngl e Fami ly P1 an 6005 ARX ADD ❑ �1 1 9.6 A - ALiER �� FINAL (� y� Q ./ ¢"m � w �G"� � B.&P.C.for this reoson � DATE G3 ,s�< 7� REPAIR � . � uSEOF BNAL � -I `-3GS'S,� U Date: EXISTING BLDG. DEMOL ❑ �y� Signature APPLICANT TEL Y e��?Z',,� �):j . OWNER-BUILDER DECLARATION .. PRIN7) NO. � 1 here.by affirm ihat I am exempt from the CoMractor's License .. , � Q ;,�:L!�'-t��1 Law for fhe following reason(Section 7031.5,Business and RDDRESS -- - -��-- - � - � � � �. �Professions Code): - . . .paeSeNi . � � �BUILDING .. � � I, as ownec of ihe property, or my e�ployees wifh ADORE55 � � - � - --��� - - � �� - wages as their sole compenwtion,will do the work and - . � � - . _'j � �,r�}�� _ ihe strudure is not intended or offered for sale(Secfion �����iiY � � . . � , - . - 7044,�Business and�Professions Code). � MOYING TEL. . - - �� � �7� �., e „ �� � � I,as owner of fhe properry,am.exclusivaly contracting -CON7aacToa NO. ^ with licensed confractors to consfruct the projecf($eo qpDRE55 � � ��1 �'�� �tion 7044,Bosiness and Professions Code). _ REQUIRED yqRD HWY TOTAL SETBACK FROM EXIST. - , u e �'� '��,`j i,'�,� CONSTRUQIQN LENDING AGENCY � sei encK PROP.LWE wioTH -. - . - � I hereby affirm thcrt there is a constructian IeAding�agency for FRONT �� . � � - � the performance of Yhe work for which ihis permit is issued -- P.L � t`�4 � ��� , . � �i c.�I� � ���� ($ec.3097;Civ.C.). � . . � . . . SIDE -�/ . - .. - Ponderosa Homes P` "' ` � ��' / Lender's Name � �� . . . .. : . - ' $ Lender'sAddre55�082 �usi'ness��Center Dr, IY�V1.Yi2 �P�C.�Fee$�- °� �',./f7 PermitFee �.,,���/, �� .. . _ � > !� I certify-that I have read ihis application and state ihat the � issuance Fee 1't�, .5'�` --- � above information is correcL I agree fo comply with.all County in�ase�gm'�on Fee - /� � � . ordinances and$tate laws relating to building consiruction, -� To�al Fee S b`/. ..9'�� and hereby aut�or za re resentatives of this Counry Yo enter m upon fhe abo. me �o e �pro ty for inspecfion purposes. - ---.- .--- ----- --�- � -` - .. . -- ....- -.. - .--. . . -... - . . . � � ��' �� � ,��'"'(�J SEE REVERSE FOR EXPLANATORY LANGUAGE . . / �s Sig�omre of pplicanr r A nt Date � - �� �--- _ _ i irc-n �y S r� r� � yaa ' -n �--r� " � �— tn� -� �y g � � � a c � °5 � � � o p�o{ � i o 0 4�m �°p� G` 9 G7 y � � i� � � � �R Q R' r ! � '7 �.� `� o � s � � lta.,Qm � .. j_�T @ � �. �' ° � h n � e q �- c;'�9� � ��� '�e�� ,i ' g � ra �.'.9 �c � r3 �Q: D Q `� - � n O r � » { � ? �� a I �' �'1 �� 't ~�� � �i „ v � _ � �.t � � � � � ��� � �q � � ° � �� � � — � � � n � � � � , _ �. � � , , �� �z� .� , ,�� � � �� � � � � `� � � � I� �O �' � I��p I' �� �A � Q �� � � Lin . � � r o� R �� � � � � �g.� p � I ! k 3 1 p§ V � 7 � . 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