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HomeMy WebLinkAboutNo Permit Number � WORKERS'COMPENSATION DECLARATION . � f' i hereby�affirm that�l have a cerrificare of consent to 5e�f ��APPLICATION--FUR�� BU1CDI-N�- PERMIT �S insure,Qr d certificate of Workers'Compensation Insurance, � � _ or a certi4led copy ihereof(Sec.3800,Lab.C.) t�' COUNTY OF LOS ANGELES . BUILDING AND SAFETY Po„�Y�9CK12723SP�mPo�Y Aetna Casualty - ❑ eu��o��� 3556 Hawk�vood. Road Cenified copy�s hereby fumished. __.FOR APPLIGANT TO FILL W nooRess � Certified copy is filed with 1he county boilding inspec- BUI:DING 10CALITY Di amond Bar non deparrme��. nooaess 3556 Hdwkwood ROdd . . . ���� � NEARES7 y . � d..a�y.zs-..� Dqle ApPlimnt an �i d(l1011d BaP z�r ceoss sr.� ;`_,�,.G.:. =><- . CERTIFICATE OF EXEMP710N FROM WORKERS' NO.OF BLDGS. �ASSESSOR COMPENSATION INSURANCE SIZE OF l0T NOW ON LOT MAP 800K PAGE PARCEL This section nead not be�com leted i4 the ermit is for one � � usEZONE MRP �, ����� P P Ta�,cr 34161-V BiocK �or No21 .,�?„- �No. bundred doilars($100)or less.) � � � � � �SPECIAL �'° OWNER Ponderosa Homes N0.��3-Z�BQ -%���� CONDITIONS� � .. I certify ihal in fhe�perFormance of-ihe wo�k f0�which ihis � DISTRICT GROUP TYPE� FlRE PROCESSED BY ,��. permit is issued,I shall nat employ any.person in any manner qDDRESS 2Q82 Bus-i ne.s5 Center Dri ve ��Q� COnlSs.-�- Z9N6 so-as to.become s�bject to the Workers'Compensotwn Laws. `�y �'��' Y- /a! �_�uy_ '-�� � � �- CITY .. I}' � � Z�P-' Z 5� STATISTICP�LCLASSIFICATION �— APT. CONDO. F� Dafe -� - ApPlicant �� � . � . � fRCFPTECTOR �� p .�... :TEL . ..f� � � N O T I C E T D A P P L I C A N 7: I f,.p f)ermo ki ng��h l s C e r t i f i c o t e�o f ENGfnIEER A r a�m i,+d$S.�I�l d l l :1•1 0 �J�4?�.8 6 4' -C L A S S N O. �-���� D W E L L U N I I S- � ' �mption, -yau-shoold becoroe�subject��to�ihe Workers' � _ .�.-:- , - . . . . � �' .ipensation provisions of the Labor Code,ybu musl forih- � ADDRE$S � � ��P N �. . SEWER MAP . � wdh comply with such�provisiuns or ihis�perrnit�shall 6e �.� ' TEL. � -BK�. PG - VALIDATION � deemed re�okaa. � � . � � coNrRActoR Ponderosa ��Homes -No 833-�2180� . LICENSEDCqNTRACTORSDECLARA710N �� dIT1E d5. dGOV@ �� ���� �3434'�5�� - - - � I hereby affirm ihat I am licensed under provisions of Chapter 9 AD�RESS 5 ��NO: VALUATION (commencing with Section 7000)of Division 3 of the Business and � � llC. $ �„� �yy� Professions Code,and my license is in-full force and effact CITY CLA55 B , �SQ. T � � NO.OF NO.OF CHECK . . � �icense rvumber 343456 uc.Closs g size�994 60 $TORIES FAMILIES oNe Ponderosa Homes oeS�R���oNOFwoRK "Ew s Coniractor �Date qoo �� � - �I am�exempt��ae�se�. � �� � - _ Si n 1 e Fami 1 y Pl an 6005 BX A�TER � F�Na� � , B.&P.C.for�his reason � � REPAiR � DATE � �f �`h�' � . �:`� 'I T,6 A � Date: USE OF DEMOL � FINAL�j�J� �.�u u � ��.� EKISTING Btu^G, By . Signature � APP41CANT TEL. . . � OWNER-BUILDER DECLARATlON - �(PRiNT NO. I �C�r 3.1 O I�hereby affirm that I am exempt fram ihe Contrac�or's License ADDRESS � ► - � -�� � � '�C U n.1.�� Law for the following reason(Section 7031.5,-Business and - Professions Code): . . �.BUIL�NG - - ..-.--- . .... . . - - �.�=i����8 U' nI, as owner of ihe properly, or my employees with � AflDRESS - , � woges as thei�sole compensation,will do the work ond - � . . . Ihe sKucture is not intended or offered far sale($ecfion LOCALITY . _ 7044,Business and Professions Code). � � MOVMG TE�� �� � I,as owner of ihe property,am exdusively connatfing C TRACTOR NO. . . wiih lirensed coniractors�o conshuct ihe project(SEc- ADDRESS - - �� � /7 A .fion 7044,8usiness ond Professions Code. - - �` " -- - � �REQUIREU TOTAL SETEACK FROM EXIST. . . �,[m � m e m� CONSTRUCTION LENDING AGENCY � SEI BACK YARD HWY PROP.LINE WIOTH . - , - � . � - I hereby affirm fhat there is a�consiruction lending agency for FRON7 ��,+ / J , � � �j� j,Jr�! the performance of the work for�which ihis permit is issued R�. `tf �.� /�`"r 4"� " � � - � - - (Sec 3097,Civ.C.). � . - . - .. pllE ;!� Z Q /.�! � �' a�? 1.�...�,Q� . 0 Lender's Name Ponderosa Homes _ .. , , � � - � . . � � � . . � � �y � i;'i,2/�.LL_8� � 2082 Business Center Dr, Trvine P� FBea � � ��' PE�m��FBe -��'�` Uc - Lender's Address � . . i . �� ��- --����- - � ��. � I certify that I have read this applicption and state that ihe � Issuance Fee (O. SF-� � above information is correct I agree to comply with all CouNy Invesrigation Pee � �. ordinoncas and 51ate lows reloting to building construcPion, � Total Fee �5�� a-� u and-hereby uiho� �C�presentatives of this CouMy fo enter - . _ . � upon the ab ue-i tlone operty for inspeetion purposes. . -- - -- -�-�� - � � �: � '� . t-f D� �� SEE REVERSE FOR E7(PLANATORY LANGUAGE - ��� n Signatura'af Appli ant r Agant - Da�e - �'' �J � r— "m g r i gy� � g . _. -'� � �8 17 s'D O g -�..� � '� � � � � p O � I � � i 9 �� �I� �1 � p tp'���0' � ' � � � CVO � C s � 3 a- 3 e3-Q� � i � � � � n � rt j �- ' C3 � � � s f � � r o �� I ��� K ' � � � � � O ,� I -.I �. � �� � ,� d � � � � � �� � � � �� � -��� -- � � � � � �-� � �� � � � � � <� � � �, sr� � �� � �� � �� �c � �0 � w 6- G S,� � . �! 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