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HomeMy WebLinkAboutNo Permit Number � WORKERS'COMPENSATION DECLARATION - � � - � I here6y affirm�iFiai � ho�e a certificofe of consenf�fo self APPLICATiON FOR BUI�LDING- P-ERMIT insure,or a certifimfe of Workers'Compensafion Insurance,- �. - � or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY Policy nr�9CK1�2723SP�mpony AGtlld Casual ty. . , � . ._ . .---_ _.. . . _ � CerGfied copy is hereby fumished. FOR APPLICANT 70 fILL IN B""o'"� 3567 Hawkwood Road A�DRE55 � Certified-copy�is filed wiih tke cduMy�6uifding�inspeo- BUILDING fion depor}menf. . - . . � ADDRESS� 3567 HdWICWOOCI ROaCj . LOCALITY Dl diTlOnd Bd1^ � - Date - - A licdnf CITV NEAREST . .:pP D zia cRosssr. •. ��-��.�/ �c-� �J � CERTIFICATE�OF�EXEMPTION FROM WORKERS'- - " � � No.OF BiocS. nsse55oe � � . COMPENSATION INSUBAfVCE $PZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This se[fion need not bB tompleted�if�fhe permit is for one � USE ZONE MAP �„ hundred dollqrs($ioo)o�less.) � � - TRACT34'�6�-V gLpCK LOT ND.�5 No. -.r;s:� 1�certify thot in the pert6rmdnce of ihe��woik for whicM this oWNER Ponderosa Homes nio.833-2180 `�If�`� CONDI710N5 . �y,�„ permit-i5 i55uerJ,I SIIaII not emplOy any.person in ony-manner � � -DISTRICT � GROUP�TYPE �. - �FIRE �PROCESSED BY � so as fo be[ome_ffubjecf fo the Workers'�ompensation Lav✓s. ADDRE55 ZOHZ BUS�YIeSS Cente.r Dri ve ���� � CONS�•- ZONE �- 6.,9 ; c�t� Trvi ne z�P 92715 s'r� r1`'�•s` ..� f� ��...���- � Date �� Appl"cont _ �- . � , :� .� . STAiISTICAL CLASSIHCATION �--qPT. CONDO .-g� NQTICE TO APPLICRNT: If, afrer makin ih(s Certificate of �. ARCHiifcioR � ' iei. _� -- g eHGiNeeR Rram BdS5eYlidYi ' t�o 75'Z-1864 '�/ `mption, you should become subject to the.Warkees' �� � � CL/{SS�NO. »'-""��`-bweLL.UN�75.� . - . � ._� :npensation prpvis ons of fhe Lqbor COde,you mUst forfh-- '. . qDDRE55 SEN/ER MAP -'-� --- --�� -�- - � with wmply-with such provisians or iFis permit sRall be , �. �� � _ . . � �' aee�,ea�e�okea. coNTaocTOR . Ponderosa Home�;. 833-2180 ' .� /�=� `� ..-aK. PG, VALIDATION LICENSED CONTRACTORS�ECLARATION � � � � - ��C. � � ' � � I hereby affirm ifiat I om licensed�nde�p.o��s�o�s oi chaP�e�v � AooR�ss -same �as-abpve . � No:. 343456 �- (wmmencing with Section 7000)�of Divisio�5 3 of the Business arid - � - - �� VAIUAT10N � �� -�-�-�- Professions Code,and m license s-in full forcz and-effect. ���' �`��y � r arr c�ass g s u�e�se N�mbe, 343456 u�.a�s B s°��31/63 STORI�ES AMILOIES oNeK __ � conrrocm� Ponderosa Homespafe oescR��r�oNOFwoRK NEW $ Single Family Plan 6 CX p'�� ❑ 2�4F, �I am exemPf under Sec, q�TEg � FINAL �r ''� 8.&P.C.for this reason - � � � - � UATE �o�J � REPAIR y USEOF 1,,, ��"� � �� �?.I - Dofe: - EXISTINGBLDG. DEMOL ❑ BNAyey�.��,r1 ,,1 F, Signafure . . . . APPLICANT TEL. y �P�� I ��a.�2 5 4 OWNER$UILDER DECLARATION � - PRINT) NO. � � 1 hereby affirm ihat I am exempt from ihe Caniroctor's License . . , ► `��J��� Law for ihe�following reason�(Section 7031.5, Business and ADDRE55 .. ..__.. _ . _. . .._.. . 9 /_.._. ___. PrOfC55ior15 COtJC�' ' �� � � �� - PRESEM �1 f �"���('�' f� BUILDING � 1 I, as owner of ihe property, or my employees with . �_AD�RE55� --- - � - -�-- -. .. ages as their sole compensation,will do the work and � �'�' � �� ' ' � �-� -�- � --'-- `_ - �- � - --� -- w - the sirucWre is not intended or offered for sale(Secfion �OCALITY� _ � �� . 7044,Business and Professions Code). . . � . . . MOVING TEL. . � � , `%� ,%(1,5 f� Q I,as owne�bf fhe properfy,artl exclosrvely cOntraciing . LONTRACTOR NO. . .._____. _ ..._.__ -..� with licensed contcactors to construct ihe projecr-(Ser - � 4�+v , � �� � � �tion 7044,8usiness�pnd ProfessionS�Code). - � ADDRE55 � F �REQUIRED� TQTAL SETBACK FROM- EXIST. '� I iJ(�,i,(j(j - CONSPRUCTION LENDINGAGENCY �� �� Sei BncK� YARD Hwv pRor.�wE --�-- wrorH- . -.�- - - �� I hereby affirm ihai ihere is a construciion lending agency for FRONT ,rj q - " � -. - _ ..._ .w ��(;':;.t�i}� _ the pehormqnce of the work for which fhis permit is issued . �p,L ,P'��`z°'- €`� d°j�- �G? � � . � _ � (Sec.3097,Eiv:�C.). .. :_ . .� .. . . �- . SIDE ( ��, , -._ . . �J�.r°U�_'C?�4 Ponderosa Homes P� � � �'� Lender's Name - - - � . , . $ 2082 Business Center Dr, Trvine P.c.Fees �'_�,�. -�"H' Pe�m;,Fae �y,l,�a � Lender's Address ' � - � . i . . . . �. . � � . . . I certify}haf P have read this applimtion and stafe ihot the � � � Issuance Fee .�a� -�� _� - � abave informafion is correct.I agree ta comply-with.all Counry 1nvesrtga��o�Fae ` ordinances and Siate laws relafing fo building mnstruction, Tota�Fee !c�_� o G`� u ond hereby cq�iho ize..cepresentatives of ihi5 County to enter ----- a u on ihe.abo�e- enf ne� r ri f r i �- � � - m o d +�e o ns ecfion� ur oses. ��-� �� � � - �� -1"w� -p f�1�:f)�` . SEE REVERSE FOR EXPLANATORY UNGUAGE � !n Signatur f�Applic t o Ageni .. .. . . _.�are . . ....__. ._. . . . . ..___.. .__ _ _ . ___._ ... .. _. .. . . . . _ _._-___�f . h . n v s u^ e� � a ,�_ w ,. a 5 O� . � �!- � .; � C � � � � g � 'n'� �' � � �„�n,.�`''�=\ c .�''Q. h� � �,. � �. . u� �"i,� cn�.. � P� �.p. ry. �..m O�„.•� r U� � �� o�i'e'w �-� �' U7 � c� �.�a � - [ i � p C ,.�1�� +� W'�wW� Gy�,"�'190 �,�8`' w�Ow�,'��": a � ��� � � e ':O N�. � . . � . 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