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WORKERS'COMPENSATION DECLARATION _ _ - . �'j APPLI�ATiaN FOR BUILDlNG PERMIT � I�hereby affirm iRal I'have a certifimfe:of-cohsent to self - jy� insvre,�or a certificate of Warkers'fompensation Insurance, -�- - - or a certified copy thereof(Sec.3800,Lab.C.) SOUNTY OF LOS ANGELES BUILDING AND SAFETY a YNo59CK12723�PAPa�Y Ae.tna Casualty _ _ _ Certified copy is here6y furnished. _ fQR.APPLIGANT TO FIL6-4N- ---- ADDRESS 354$ HdWkW00(� ROdCI � Certified mpy is tiled withlhe covnty 6uilding inspeo- gUILDING r�on dePorrme�i. aooeess 3548 HdwkW00d ROdd it�cnuTr D1 am011d BdY' ' � � ' NEAREST Date - Applicant c�T� �iamond Bar zia CkO555L� �� . -a ��^'�t�"' CERTIFICATE OF fXEMPTION FROM WORKERS � � NO.OF BLD65. � �ASSESSOR - ' ' COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This seciion need noi 6e completed if fhe�permif is for one 34�6�-�j � � 22 -USE-20NE -`-ftKAP� ����n��� hundred dollars($100�or less.) � TRACT BLOCK LOi NO. ,�^,"�,f� NO. . . TEL. � -SPECfAL o I certify fhaf�in fhe performance of ihe work for which this OWNER Ponderosa Nomes n,o.833-2180 !�a`c'� CONDITIONS. .. . '��. permit is issued,I shall not erpploy any person�in any manner � � ���ISTRIQ GROUP TYPE FIRE PROCESSED BY S� so.as to become su6'ecf to the Workers'Com ensation Lows. AooRe.55 2082 Busi ness Center bri ve #��� CONSi,,,..��- Z01'r E . �t� � . .p . /a�i' - ,�.-� � 1 t�,. ��u,..:�� €H �ate Appl�cant' cITY TPV1Yl2 zIP gZ��rJ �"`� � ARCy17ECT OR iEL� SiAi15TICAL CL4551FIGTION.. �qpT. CONDO. � NOTI�E TO APPIICANT: if, after�makmg �h�s Certificate of � ENciwEeR.: �F"dTil'��d552Yll��dil {v07�J2-�86� �ets.SSNo. ���� - oweu uN�rs�� - � mption, you�should become subjeci��to 9he-Workers' � � - ,� � . �. � � .ipensation provisions of theipbor Cod�e;you musf forih- ' � � qppRE5S�9��.W@St@Y'� �-P�a N24+1-.Q}"� BedCh ' SEWER MAP� � .� � - -. e� wifh comply with such�provisions or,this permit�5haIP be �- � � � VALIDATION- � deemed revbked. CIdBY'OSd H01112& NO 833-2180 eK. P�, /�`�' eoNTRAcroe LICENSED CONTRACTORS DECLARATION �� � �. -� � � � - llC � � I hereby affirm fhat I am licensed under provisions of Chapter9 ADDRES5 ShcTle dS dbOVQ �Nl�:3434rJ6 - VALl1AilON � - (commencing with Section 7000)of Divisio�5 3 of ihe Bosiness and � I.IC. � - � -Professions Code,and�my license is in full force and effett. CITY CLA55 B $ �C?� d'a-'� , � - SQ.-FT. � �- NO.OF �� �NO,OF -- CHECK License Number 343456� � �� i;�.eiass B � si � sToeies FAMILIES oNe - � - � - - POYIdC�Y�O$!� �OITIe$ � � � � �DESCRIPTION pF WORK- NEW � $ Conirnctor Date . - - - -. . ❑�am axemP���ae�se�: Si n 1 e Fami 1 P1 an 6 AX ADD ❑ . n�Tek � FINAL ��� �� . 8.&P.C.for ihis reason � � DATE `=1 � �.5 p, , REPAIR � . . Date: USE OF DEMOL ❑ FINALdrp,��,y, _ p ;�W'�� ° $�'I .. EXISTING BLDG. gy �✓ �/L.d1-(�< . .Signqture� � APPLICANT TEL. . . � ) �J G J.�✓� � OWNER-BUILDER DECLARATION� . PRINT) NQ � .� �n .,s I hereby affirm that I am exempt from ihe Coniratror'S License � ►�__ � � 7 r J y�;c,> Law for the following reason(Sedion 7031.5, Business and ADDRESS. . . - � - � � � Professions Code): . . � p e5ern' - Q 'i,-�3����"�g�. .n � - - .. '�BUILDING . . .. . ._. . . � � I, as owner of ihe property, or my employees with ADDRESS ---- -- � wages as iheir sola compensation;wlll do the work and -�- � � � . ihe siructure is not intended or offered for sale(Section LOCAlI7Y .. .. � 7044,Business ond 7rofessions Code), � MOVING TEL. - - � � � � I,as owner of�he property,am ext�usivel contracfin CONTRACTpR NO. � ' with licensed coniradors to constroct ihe project(Se� � .. . - �� � r�9 A tion 7044,Business pnd Professions Code). ADDRE55 . - ._. � � - CONSTRUCTION LENDING AGENCY � �-�REQUIRED�- YARD HWV TOTAL SEfBACK FROM EXIST. " #g.`" � e � SET BACK PROP.LINE W�DTH - � �' I here6y affirm that�here is a construction lending agency for .FRONi � 6 . ► - . � � � - � � '�-�J J 5,(�Q the performonce of the work�fo�which this permit is issued RL t�l L� /'� l'�� . (Sec.3097,Civ.�C.). - . �51oE � l . . - � .� � - � .. � � �J r c;,�C'U Ponderosa Homes P� �� � l�� � �e�ders Name_ C�1 ,',_��-�8 4 Lender's Address 2[�82 Busi ness Cntr Dr. Zrvi ne �P.C.Fee$ ,j��� �� Permit Fee �.�������� -' � I certify ihat I have read fhis application and�state that fhe � lss� ce Fee ��� �+� � above informaiion is correct.I agree to comply witM.all County ,Invesrigation Fee - � $ ordinonces and�5tata laws relofing fo building construtiion, 7otol Fea „i.i 3 i rj fy u qnd here6y thoriie representatives af This.Couniy to enter � n upon r�ab ve- en'" ned r perfyfor inspection purPose� � . � � - � ' g ��JU",�j , SEE REVERSE FOR EXPLANATORY LANGUAGE Signaiure f Appli nt o Agenr - Da(e '� - � -�6 � � 1 �� � T .� ' � u� ' � � -ei_n r ara . -as tn ^s � � � ° r' � �4✓n � =ev� @ 4�2 � � � o o Q W � � � � �.�:�� 4 o p� t� c� ,� �� -'Q� g � � @ O c T s � � � � �O � .-� � � n � SD � � � �: t5 � � in � �� � cs � n o� � ' � v a c�: � � +� �- ' � €1 .� 3 i= � � % °,c v � � ��� :� � � �' � `� � '--e� ry� � ' � §'�� � k F � °� � � � � a �,� ^ a C�i� .S Y o ^.�v � 'i ��. �{ � � � F� sl'> � � C�a C .,� a � E .��, � -S .4; �� <] .� � �: =;3 pg �f I �. � ���„' � � i o: �j_ � i �, �, ; i i; e� � � � � � ��, rj:.� � °� , .�: � . ��..7p i... � , -� � c' . _ ' ' �G � � �,, ' � , S�^ � u �i �ti ��. �� � {' � _� �4 w � � �; � �Q � ,�s� �. �� a�7 � , � � � � � ��� k 9 9 d 3 � I h " 7� i j 1 � � � � �' �', E ' i, i � � � i � , � �' ; a �� ` � � �,.�,�.a.��, `.��� '�> � __._ _I.__. � . � � � � � � � , � ; t� ' ��i g ' � q " � _`� � � ��,� � � �. { � � �.> �. ;��L � � � � � � � ! � ; I ' - � � ��, � �o � 6 � �;_,_ _ a_k� � � �...s � ��. � � i� � ,� , � i � � _.,.�_._ �_.��.�._r.._ ` _i_ � h ._.—� --�---�i� ,�.. , � ' � i � 1'4����' y� i�, �� � I f : � �,, � , � � � � � ' �' , . ---� � I p ,� ; �� �t � 5 � `�' � ; 4�� �.w_.. �--.•��—x�--��—�--� � � � � �' � I i. i �� & ;� . �_ � k 1 � ��,'� � I� j� � I � � i � i � � �` � � " j j „ � �� I � � °� �� I � � � ` �--a �° � � � �. �e 3 � � ��i fl � � ! � � � � � �_ � i � � _ � � i � � `� � � � � � �� � " � � ' ` � � I �' � � ± � I � � � � _ � � � � ' f � �4 � � I , � � �� � I I..._.__� ��.d_� _^ :.— i� _ �_ __��.. �_--��-- :�:�. �r..� .�...:_. i �.�. , .� .....r�.m.,, ' ,� i � � ! i � � ( ! � � , I "� � � i � ; . � li � � � � � . `_;� �� , �� . � 1 � .� i � � 1 � 1 . 1 ! � � � a �� � ' � � ���� � : 1 � � � � � i � - �; � ' I � � ; ' "� � � � � � � + f ' l R' � ; ! � j s � q ( i � I j ' ; I � � �I i ; � ; i � � � � � � ; � �I � � , I � � , � � ( ,� � ( � � �� ''s, i �: { ' ± � I � i ; �� 1 � ` l � '' � 1 � � k ; s � � , I ; + � i � � � � ! �� ; � � � � � � �] 4 i 1 � , , I � , �� ., j �'. � ' � � ; 'i . . _ � � --d � �j . � � �' i I ��' �I � ��e . ; I . 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