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HomeMy WebLinkAboutNo Permit Number (4) � WORKERS'COMPENSATION DECLARATION . �� �' i hereby�offirm ihat�l have a cerrificare of consent to 5e�f ��APPLICATION--FUR�� BU1-LD1N�- PERMIT �S insure,Qr a certificate of Workers'Compensation Insurance, � � _ or a cert�fled copy ihe�eof(Sec.3800,Lab.C.) �� COUNTY OF LOS ANGELES . BUILDING AND SAFETY Po„�Y�9CK12723SP�mPo�Y Aetna Casualty - ❑ au��o�v� 3556 Hawk�vood. Road Cenified copy�s hereby fumished. _ __.FOR APPLIGANT TO FILL W nooRess � Certified copy is filed with rhe county boilding inspec- BUILDING 10CnLITv Di amond Bar ..fion deparfinenL . � ADORE55 3556� Hawkwood Rodd . . ���� � NEARES7 . � Dole Applicant CRY Di�amond BAr � z�P �Ro55sT.� ;`_'�'.,:,. �=>_- . �-��`�'�'� � CERTIFICATE OF EXEMP710N FROM WORKERS' NO.OF s�oGS. �nsse550a COMPENSATION INSURANCE SIZE�OF l0T NOW ON LOT MAP 800K PAGE PARCEL (This section need not be�completed i4 the permit is for one 3[�,�6�-V � Z lISE ZONF. MRP �, ����� bundred doilars($100)or less.) � � � � T�"�T B���K lOT NO � ,�?,i- �NO. �y SPECIAL � OWNER Ponderosa Homes N0.��3-Z�BQ - /��� CONDITIONS� � .. I certify ihal in fhe�perFormance of-ihe wo�k f0�which ihis � DISTR7CT GROUP TYPE� FlRE PROCESSED BY � permit is issued,I shall nat employ any.person in any manner qDDRESS 2Q82 Bus-i ne.ss Center Dri ve ��Q� COnlSs.—�- Z9N6 so-as to.become s�bject to ihe Workers'Compensatwn Laws. ��y ,�'��' Y- /�� �_�z�.,;._- � � � �- CITY .. I}' � � Z�P�-' Z 5� SIATISTICP�LCLASSIFICATION ' APT CONDO � Dafe -� - ApPlicant �� � . � . � P,RCh11TECTOR �� p .�... :TEL . ..¢� � � NOTICETOAPPLICANT� If,.pf)ermoking��hlsCertificote�of ENGWEER Ara�mi,+tlS$.21�1d11 :1•10 �J2?�.864' --CLASSNO. �-���� DWELLUNIIS- � ' �mption, -yau-shoold becoroc�subject��to�Yhe Warkers� � _ ��.-:- , - . . . . � �' .ipensation provisions of the Labor Code,ybu musl forih- ADDRESS � ��P N �. . SEWER MAP � with comply with such�provisiuns or ihis permif�shall 6e �.� ��� jE�, � BK � PG - VALIDATION � deemed re�okaa. � � . � � coNTRActoR Ponderosa ��Homes -No 833-�2780� . LICENSEDCONTRACTORSDECLARA710N� �� dIT1E d5. d�OV@ �� ���� �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 trc.Closs g sizei 994 60 $TORIES FAMILIES oNe Ponderosa Homes oeS�R���oNOFwoRK "Ew s Coniractor �Date qoo �� � - �I am�exempt��ae�se�. � �� � - Si n 1 e Fami 1 y Pl an 6005 BX A�TER � F�Na� � , B.&P.C.for�hls reason � � kepqiR ❑ �ATE � �� `�� � . G 1 'I T,6 A � Date: USE OF DEMOL � FINAL�j�J� �4 � � �Z.� EXISTING BtDG, By . Signature � APP41CANT TEL. . � OWNER-BUILDER DECLARATION - �(PRiNT NO. I �C�r 3,1 O I�hereby affirm that I am exempt fram ihe Contrador's License ADDRESS - ► - � --� � � "C U n.7.�� Law for the following reason(Section 7031.5,-Business and � Professions Code): . . �.BUIL�NG - - .-.-. - .... . . - - �.� ��4���U' nI, as owne�oF ihe properly, or my emplpyees with AflDRESS - , � woges as thei�sole compensation,will do the work ond - � . . . �he sKucture is not intended or offered far sale($ecfion LOCALITY . _ 7044,Business pnd Professions Code). � � MOVING TE�� �� � I,as owner of ihe property,am exdusively connatfing C TRACTOR NO. . . wiih licensed contradors�O conslruct ihe project(SEC- ADDRESS - - �� � / 'A .fion 7044,8usiness ond Professions Code. - - �` " -- - � �REQUIREU TOTAL SETBACK FROM E%IST. . • �,[m � m v 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� M.5�! the performance of the work for�which ihis permil is issued R�. Y-� <� /`l �� ' � � - � - - (Sec 3097,Civ.C.). � . � . SIDE �i �.! . � � a�? 1 �...�.Q� . a.t. f.z �E i�: < Lender'sName Ponderosa Homes ._ .. � � - � . � �� � . . � �,_ � i;'i,2/�.LL_8� � 2082 Business Center Dr, Trvine P� F�a � � �n PefT"FBe �'�`� `�c - Lender's Address � . . i �� ��- --����- � � ��. � I certify that I have read this applicption and state that ihe � Issuan<e Fee (O� s�� � � above information is mrrect I agree to comply wi�h all CouNy Invesrigation Pee � �. ordinoncas and 51ate lows reloting to building construcPion, � Total Fee �5�� a-� u and-hereby Who� �C�p�esentatives of this CouMy fo enter - . _ . �g upon the ab ue-i t(one operty for inspeetion purposes. . -- - -- -�-�� - � d : � '� . l—JD� �� SEE REVERSE FOR E7(PLANATORY LANGUAGE - � n �'�(Appli ant r Agent - Da�e . . .Os �'' �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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