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WORKERS'COMPENSATION DECLARATION � �� insureboiafcertifcate 4pWorkesr'Compensafion Ins�rancef � �- - -R'IPPLICATI:�N�-� FQR �:BU-IL�D-I:NG- PE�MfT � or a certitied mpy ihereof(Set.3800,Lab.C.)� � . Pol�cyNo59�K�2723�a�Y Aetna CdSudltV COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is here6y fumished. FOR APPLICANT-TO FILL W no R�ss 3559 Nawkwood Road + � Certified mpy is filed with the county building inspec- auaDwG r�o�dePa�rme�f. nooRess 3559 Hawkwood Road �ocnuTv Di amond Bar - � ' NEAREST � ���¢,.- Date � �Applicant CIN ZIP CROSSST. � -^9'�'' �� CERTIEICATE OF EXEMPTION FROM WORKERS � NO.OF BLDGS. �ASSESSOR � � ' COMPENSATIOIV INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK 'PAGE � PARCEL (This section need no�be compieted if ihe�permit is for one � �� ' U5E zoNe"� � MKP � /d/L,v���� RAa34161=V BLOCK LQT NO.84 � NO '� % . hundred dollars($100)or less.) � � - .. . TEL -� � SPECIAL - - 3- I certify�that in ihe performance of the.work for which this OWnIER Ponderosa Homes NO 833�Z�8� ��"� CONoiTLONS �� permit-iS�i55Ue[r�YShaIIIiDFemployany:pe�sonin�anymartner - '-- DISTRICT GROUP-TYPE FIRE PROCESSEDHV � so as to bewme subject to ihe Workers'Compensation Laws. - ADDRESS 2�$Z g1151 Y125S_ �'.Erl'teY� �1'1�V@ #��Q CONST. �y- ZQN� ,f� � . . - !`� - �.� � .a�-f°� .:.�-� t1-f-��`°"./ � c,TY T rvi ne z�P 92715 ` ' � Dafe � -� Appl canf- �� � . � �. . - STAT15TICAL CLASSIFICATtON APT. CONDO. 5� NOTICE TO APPLICANT: If, after��mnking th.is Certrficate of .4RCHITECTof{, 7E� ` :�. . �. ��,� `s3 . ENGINEE,R:: HY'�R1'B�rvS21�I�� N07�Z-1� `'T4 :CL4SSNQ. ��'� -� DWELL UNITS��y4 ' '�='� �mption, yau should became subject��to the Workers' - � .� . ,� �. � , � -� �. .npensation provisions of the Lpbor Code,you mUsf forfh� �� hD6RE55� 3�9� -wQ$t,QY'� -'�P�dCQ�-��W OY`� BC SEWEIt MAP � � - -� � with comply with such provisions or ihis permk�shall be �- � �,��J,�, � � � deemedrevoked. . � � POIlF�21"DSd �H0111@S TE� $33-Z.�HO , BK. PG,- VAUDATION . . . CONTRliCTOR . �-.�1+10. � LICENSED CONTRAC70RS DECLARATIQN `� - � - � � ����, - � � . I hereby affirm that I om licensed under provisians of Chapter 9 � ADDRE55� SdiY12.dS. dI�OVe �- NO:34'�4'S6 VALUATION � (commencing wiih Section 7000)of Divisiof�3 of ihe Business and � llC. Profess,ions Code,�and my license is in�full force and effed.� CITY . CLASSB � ► � - � 5 7- NO.OF NO.OP CHEIX . � License Num6er 343456 �;�.ciass g s� STORIES FAMILIES ONE I � ConiraGlorPOCIdCY�OS(���HOIIIGS �pa�e� � DESCRIPTION OF WORK NEW $ a r �� � ' � Si ngl e Famul Pl an 364 BRX ADD � ` � ��'`P �I am exempt under Sea ' - � � , ALTER � FINAL @� �/ f��/� � DAY� c'1 sZ7� �3 T Sa� m o a.c� I B.&P.C.for fhis reason � ' REPAIR � � . . Date: E ISTOING BLOG. - DEMOL � FIN/AL � "''g i��� - APPLICANT TEL. By �� , � . Signature � . . . PRINT) NO. ...- . `�''����� �1 V a OWNER-BUILDER DECLARATION � - - I hereby affirm ihat I om exempt from fhe Coniractor's license . ,__ �1,i J-"`��1� Law for ihe following reason(Sedion 7031,5,�Business and� ADDRESS ��� -� - ^Professions Code): � � � . - pae5eN7 � , � I I, as owner of fhe�property, or my employees with qooRe55 � � � - � -� � � ��wages as their sole compensation;will do the wprk and - � . � " the strudure is not iMended or offered for sale(Section LOCnu7V� � � ' � . ��� �Ci,�5 F - 7044,6usiness and Professions Code). �� � � �� MOVING 7EL. � � - � � - � I,as ownet of ihe property,am exclusivaly confracting � CONTRACTOR NO. . . � �*'° � �' "� °� with licensed contractors fo consiruct fhe project(Sec- qDDRE55 � ° r'7�����) Yion 7044,Business and Professions Code). . `� - - � - REQUIRED- TOTAL SETBACK FROM EXIST. . �� s � CONSTRUCTION LENDING AGENCY� - � ser�encK �ARo Hwv pROP.LINE wioirf - -� �' " 7 � Ci:Q Q c.o-� I hereby affirm ihat there is a construdion lending�agency for FRONi - ' - � � � � - the performance of ihe work for which this permif is issued P�1�. �� -9�' �� r_+ , fi 9 2/���-'�j!i . (Sec.3097,Civ.C.). . � . . .SIDE .. . - � - Ponderosa Homes P` r �"�'`"��� Lender's Name s� . . . � . .� � 2082 Business Center Dr, ZY'VIYI PCFee$ 1�,��."7� PermitFee >h'^7�„"-.'� Lenders Address � � - � . ' � I certify that I have read this applicption and state fhat the � � � �issoance Fee I!J.��%� � ¢ above informafion is mrrecf.I agree to tomply with.all County Investigvtion Fee � � g ordinances and State laws relafing to building construction, - ia�nl Fee ,� (%` , /f� P� and kereby au�horize repre entatives of ihis County to enter . m upon the bov nention,dJ roperiy for inspechon purposes. ,� . . .- . .- - -. ..-.---- --�-— --.. . . .-_..—.-- .-.. . . . .. . .. . .. o � - ��i� �/S'�- SEE REVERSE FOR EXPLANATORY LANGUAGE � Signa� f A lica r or Agent � Date � � ��s : � LL.��`}��' _ � s= ��� a �; -�' u' '' p' B en o Q o �c�".�;-� � f'i �? 2 < :.��sa � wQ � c s s @ 3 � ' � ��� s.. �" ss � `�° 3 � � °� � �v o a ;��-j$ � � .�a � p n cE � �Q�-.�p � dJ � �gp Q o� � � . � Cy �y .°n�� �� ' .� � 3' �� � `3 `i. . �{' � .I � � I 'T� €'C� � 4Dtl.�'� 63 _ � �� I � �{ � . � _k �� ^{ySa� � � � ¢� � �r � g k Y .; d�t � . q � i � k � p' � � i �� �� �� � �� �� Q � . u g,�✓ � � � � � �.. 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