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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATION DECLARATION . . - �� I hereby affirm ihat�l have a certificate of.consenf to self ��� .Qpp�,fCAT�ON- F-OR�:BUILDIN��G-� P-ERMIT insure,orp certificate of Workers'Compenwtion Insurance, - -� . . or a certified mpy the�eof(sec.3800;Lab.C.j [QUNTY OF LOS ANGELES BUILDING AND SAFETY rQ�,.rvo59CK12723�,f'�,Pa�V Aetna Casualtv BUILDING Certified copy ishereby turnished. ' FOR APPLICANT TO FILL IN A�uRess 35F)2-HdWIEW00fI � Certified copy is filed with ihe couniy�.6uilding inspeo gUILDING - tion-deportment. . /.�oraes5 3562 Hawkwood Road �o��iT�' Di .�nd - . � - NEAREST Date . � . Applicant � - C�iy ��1dfll0lld BAP � Z1P ceosssi. (��e'�.-.E_ -�:`�, . �s&,�-�.-�" CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF eLDGS. �A55ESSOR - � � COMPENSATION INSURANCE SIZE OF LOT_ _ NOW ON LOT _ MAP BOOK PAGE PARCEL . (This section need nof be complefed if ihe permit is for one � � -USE�ZONE�-� MAP- �� hundred daur,rs �ioo)o�less, TRACT 34161-V B�ocK ioT rvo f�/ No. �'�--�' � � ��. SPECIAL �_ owNe� Ponderosa Homes No.833-2180 ���' CONDITIONS � I certify fhqt in the performance of�he work for.which this - - - DISTRICT .GROUP TYPE �FIRE �PROCESSED BY � permif is issued,I shall nat employ any person in any manner AD�RESS ZOSZ BUS1 YI25S CeI1t8Y' DP ���� CONSS.__.--_ ZONg... �- � so as io�become su6jecl ta ihe Workers'Compensotion Laws. � -� �!�„ �� �_,�s, �� : arY Irvi ne; ZiP 92715 !'� d�''�' -�z`` �5 Date �- - Applicanf� �' �� .- ' � qRCF{ITEGt p��� �-� TE�' :' STATISTICALCL4551FICA?ION. . APT. CONDO. '� NQTICE TO APPLICkNT: It, affer making this Certficate of � C �- � � "�� �� � '-'mption, you�should.�beGome sub�ect-�fo �he Workers� � - ENGINEE¢�,- F�aITr iJaS'SeI��aYI 1� 7J�'.�864 , 'CLASSNO. ''���� �DWELL UNITS � hhry Ee. ipensqtion provisions of ihe Labor.Code,you rr1Us�fOrth- � . � qDpRE55-399U�W�$'teY'� �'-��.�P{ �EW� Ol"t'B�dC�I � SEVJEP MAP- - � - - � � with comply iih such.provisions or�fhis permit�shal4.be .�. � � �-SEL � �,ry VALIDATION �' deemedrewked. . � . � � - CONTRACTOR PQndeP�$d`HQme$ �� �NO. 8'33-.2�8� ' .�eK�.fl PG, ��-�,,..Zs� LICENSED CONTRACTORS��DECLARATION �� � - � �� �� �.LIC: _ I hereby affirm that I am licensed under provisians of Chaprer 9 - /+ookE55�� -NO.343456 "-VACUATION- � (commencing with Section 7000)of Divisiorl 3 of ihe$usiness and � ���. � 9 ) Professions Code,and my license is in full force and effect. � CITY . CLA55 B $ � � �z� ► .PT.�� NO.OF NO.OF CHECK . . . �,�e�se N�mbe, 343456 u�.cia55 B s� sTOR�Es FAMILIES ONE ' . . .. . NEW XX� $ . ConiraCtof �P�naer�$a HOme$Date � DESCRIPTION OF WORK . . _ Si:n le Famil Plan 2200 BRX ADD ❑ �I am exempt under Sec. � ALiER � FINAL ,�1�1��;,/ . B.&P.C.for this reason � � - REPAIR � DATE : �0 ! `7" �� 17,AA Date: USE OF DEMOL ❑ BY'4L����� �2 v o o �+�'� EXISTING eLDG, Signature � - � � - APPLICANT TEL. -OWNER-BUILDER DECLARATION vRWi NO. I hereby affirm that I am exempt from ihe Coniratror'S License - � , . � ��1�'2� Law for the#ollowing reason(Section 7031.5,Business and A�DRE55 � ',-7��C� e � , Professions Code):� - - � � � aee5 N � � � � nV, as owner o'f the�property, or my employees with ADDLRE�55� � - � �'L G'�'�1�- " wages�as their sole compensation,will do the work and � � - � � � �� . ihe_str�cturs_is no1 in.tended.or offered for sale(Section lOCniiTv ___ .. . . . .�,.. . 7044,Business and Professions Code). � � . MOVING TE�� � � � I,as owner of ihe property,am�exclusively coMracfing CONTRACTOR NO. . with(icensed contractors to construct the projeci.(Seo- ADDRESS � - � - - ��- - - 1'� '� '�,�� tionJ044,Bosiness and Professions Code). - - - . � � �- � - REOUIRED - TOTALSETBACKFROM E%IST. YAR� HWl' CONSTRUCTION LENDING AGENCY � SET BACK PROP.LIN 4V�DThi �- .. _ '�i� H a m m j I hereb dffirm that ihere is a construction�lendin a enc for FRON7 � � - - the perfarmance of�the woFk for wNich tkis permii9s-issued v.�. �'�'� ' �� �� Zd�� ► , � - � d ��}J��c't� (Sea 3097,Civ.C.). � �Sioe �r- ,,.y � � - - - Ponderosa Homes `` '��' �`�' � ������� Lender's Name - � � � - � �-- - ____ —_ __.__._.—_____ _�.- _.:. _ _ : .. � 2082 Busi ness Center Dr, Irvi n ?c.Fee� .��, .� Pe�m�j Fee -/ � °�'l� � �.�`�.�R 4 - Lender's Address ' - - �- i .__. ._.. � - � ._ .. _ . . . . . . _ _ a I certi7y that I have read this opplication and sfate that ihe � Issoance Fse.� 6•.�Q � ¢ above information is mrtect.I agree to comply witk all County I n tion Fee �� � --ordinancesvnd-Stateiaws�relatingto-buNding-canstruction, �--9��- ----�- ----�-- TorolPee ..-��� ..-�t� . .-..�.. ... . n y vthorize representatives of ihis County to enter � . � dnd-hereb a � uponiheabo'e- .�ftinned r pertyforinspectionpurposes. - ---�- �-���--- �� � - � �-��---- - � -� - - �. � �. ,�1(�s- SEE REVERSE FOR EXPLANATORY LANGUAGE . .. . . 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