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WORKERS'COMPENSATION DECLARATION � � �� I hereby affirm ihat b have a certficafe-of consent fo se�f -- qpp.�ICATIO�N - FOR- BUI�L�DING PERMIT . insure;or o certifimte of Warkers'Compensaiion Insorance, - - � or a certified copythereof(Sec 3600,Lab:C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 59CK12723S�A Aetna Casualty - _ _ _ Policy No. ompany ❑. Certified copy ishereby fumished. . FOR APPLIGANT TO FILL IN AooRe"ss �551 Hawkwood _Road Cerfified copy is tiled wiih fhe counfy building inspec- BUILDING � ronaepa�rme�+. AooKEss - 3551 Hawkwood Road �p�q�ITY Diamond Bar Dare npplicani cirv Dldm011d BdY' zia _ cRosssr._ �__ _ .-yc'J '��c�L��s-��cr-� � � CERTIFICATEOF EXEMPTION FROM WORKEItS' �� - - NO.OF a�ocs. �,vsseSSOR � �� . �� COMPENSATION WSURANCf- . SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL This section'need not be com leted if the ermihis for one - p USEZDNE �- -MAP� ��� ���. - � - - � P P �TaACT 34161-Y BLOCK LOT NO.C)3 > NO. �" hondred.dollars($100)oF less.) - . -.-� f�-{ . . - � - TEL SPECIAL I certify that in 1Me perforinance of the..work�or whlch this � -p DRESS 2Q82 BUSI nH � NO. - ���% CON�ITIONS�. ._ �� -- -�DIS7RICT� ��.GROUP-TYPE FIRE PROCESSED BV � permit is issued,I shall not employ any person��a�Y,ma��e� ' ess Center bY'l V��#��Q CONST. ZONE � :� �so as to bemme sub�ect to the�Workers'Compensation Lawa . . ��1 f��� � �G�. � ��,Y Irvine z�r 92715 � .. �-�`�" � Da}e -- ' P.pp lieanY ' � -� �� - STATISTICALCLqSS1FICATION ' APT. CON�O. &g ARCNLTECT OR � '� '.TEL NOTIGE TO APPLICANT: If, afier making-ihis Ceriificote'of�. ENGINEER Aram Bass�ni �7 �.- NO]rj2-.��86q• ClA$5 NO. ���. DWELL.UNITS �/ � . nptian,.you�should 6ecome.suhject-'to�the�Workers- � � . npensatiort provisions of tlie Lqbor Code,you m�ust forfh`- ' qo�aESs ��SEWeR n�aP- �� � � � � - ��' with comply with such provisions or ihis perrmiY�shall 6e � -- - � .� �� � � � � deemed�a�okad. �� -� � - - . eorvTRACToe POn�dero5d.��-Homes� � nio.833-2180�..�' .�gK�..IC'��.�, l�`r -�� � VAUDATION '- , �IICENSED CONTRAC70R5 DECLARATION� � � �� �� � `LIC � � '�, I hereby.offirm ihot I am licensed under provisions bf Choptar9 -ADDRESS� SaCIIQ�aS above�� -No;343456 � „A�unT�oN � � '� (commencing wifh Sec}ion 7�00)of D visiol�3 04 the 8usiness ond � -� � LIC. � � Professions Code,.and my-license s in full force and-effect. CITY CLASS B 8 ��.3 p�"1� , � ' 343456 ` g so. r No.oF NO.OF �HE�K � LicensB Number � � Lic.Class SIZ STORIES FAMILIES ONE � NEW � $ ConiraCfor POI�IdeY'OSf� HOIT�ES Date- DESCRIPTION OF WORK � ❑I am ezempt onder Sec. P�dTl ZZOO CRX �+DD �' � ALTER � FINAL ��� � �:7'2 U,I�u 8.&P.C.for this reason DATE � . . � REPAIR ❑ �1{.c � c m�"� � � USE OF DEMOL Date: FINAL� i � EXISTING BLDG. ❑ � ' APPLICANT TEL. - BY - ��@�+--� I °b YJ��,i O . � � Signature � - . OWNER-BUILDER DECLARATION� PRINT) NO. � _ J r'��`:',� . ' I hereby affirm fhat I am exempf from tke Coniratlor's Lkense Law for the following reason(Secfion�7031.@, 8usiness and ADDRESS � , � ' ,;�i �,� � . Professions Code):.. - � . . -�- Pe�5eN7 � � -- � - � ��BUIIDING . . . n I, as owner of-the properfy, or my employees wifh �ADDRESS � �--- �---�-- - --- - --- �-- - ' . wages as their sole compensption,will do-ifie work and � � � , . � the structure is not intended or offered far sole(Secfion �LOCALiiv � _ 7044,Business and Protessions Code). . . � -. MOVING TEL � � r . �;'� �+u� � � , � I,as�owner of the properfy,am exclusively contraiting �CONiRAC�OR No. with licensed mntrpctors to consiruct the�Project(Sec- �� �* � � R � fion 7044,.6usiness and Professwns{ode_).�-: _ ADORE55� TOTAL SETBACK FROM EXIST. � �G�j��� � REQUIRE�. PR07.LINE WID7H � ' � - I hereby affirm that there is a constructwnlending agency for � feONi ,(, , - - � -�� �� - -� CONSTRUCTION LENDING AGENCY SET BACK f � 9 , m �:+C ll C�u the performance of ihe work for which ihis permrt is'issued �.'P.L �7" � m '�� .��- - ,�. - ($ea 3097,Civ.�C.). . . . �. � � - � 51DE - � � � � . . - � Ponderosa Homes '�` � "`�`"` '�"�/ (J r.�4�8�,. < Lender's Name . � - �� - _ ._. . .. ... . .. _ . _._._ .___. . . � P.0 Fee$ �'� .�C�. ..�Permit Fae :'�!��.j G9. . . � . � Lender'sAddress ��Pi2 gI15l�I12S5�CIItC bY', Trvine � . . � I certif that I have read tFis a tim}ion and state that the � Y PP - Issu ceFee ,/J. ..�"'� ¢ above information is correcf.I agree to comply with all County Inves�igotion Fee �n . g ordinances_and Stafe laws relating fo building consiruction, � Toml Fee ,.��al i �(J and he�eby au harize „reseni trves of this Gounty to enter m upon}he abov -m ' neil p rty for Inspecfion purposes. . � . � - - - � {� ���� �'`[""p . 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