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HomeMy WebLinkAbout1172A 1173A (5) � WORKERS'COMPENSATION DECLARATION � . ' �� I hereby affirm thati hpve a cerfificpfe of conseni to=e�f . qpp��.CqTIO�N FOR- BUILDI-N:G P:E.RMtT insure;or a certificote-of WorkePs'-Compensa}ionlnsurpnce, -� or a cernfed copy rhereof(Sec.3800,Lab.C.) CQUNTY OF LOS ANGELES BUILDING AND SAFETY O�Y�59CK1z723 5�A Pa�Y Aetna Casuakty cerrcf�ed co FCR APPLICANT TO FILL IN ao�aess 3570 Hawkwood Road py is he�e6y furn shed. �� Certified copy is filed wifh the county building insper BUILDING � +io�dePa�+R,e�t aooaess 3570 Nawkwood Road �ocaurr Diamond Bar � � '�' . . . . . . NEAREST . �^j�! �. �ate � -Applicant _ CITY ZIP CRO55 ST. L--� ��*� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR . . COMPENSATION INSURANCE - - SIZE OF LOT � NOW ON LO7 MAP 800K PAGE PARCEL (This settion naed.00t be�completad iffHe permif��is for one - . USEZONE MAP -� TancT 34161 e�ocK ior No. 19 � No. Q�-.a.�-� hundred dollars($100)or.less.) . �� . TEL. � �' � � SPECIAL - � owNeR ponderosa H mes r,o.833-218D ����' coNnirion�s ��. I certi4y ihaf in ihe performnnce of the�w rk for w�hich fhis . . � � � ,/� DISTRICT GROUP TYPE FIRE PROCESSEDBY :y parmif is issued,I shall not employany person�n onymanner � qDDRE55 ZOS2 BUS�1'IeSS C..eY1�2}^ �r' 7��00 CONST. ZONE � +� so as to became�subject ro ihe Workers'Compensation Laws . . citr TPV'I n2' ziP. 92715 '�� '�"' "� �'� ''`"°'"`' � Dafe � ��- Appl caM - �- �- �- : ��STATISTICAL.ELASSIFICAT�ON � APT CON�O. � Nr7TICE TO APPLICRNT' �f, pfter making'thls �erificate of .� ARCMITECTO - - �., ��:TEL .� �.. �. � � 1pLon.,--you��should-become�su6�ety to the�Worker5' EN INE�R d� g�5 -�1 ' '�-NO .rj�-� � : CLASSNO.�-��'�'�DWELLUNII'S.�� � --� - � - --� . �pensafion�provisi4ns of-}he Labor Code,you must forfh qDDRE55 399Q-rVe5�2Y���.� P�aC@�� �Qlh1 OY'� 8Ck1�� �SEWfR MAP� � � - � � � ,� e with comply�wifh such pro4isions or iFis permit s6a11 be ��� � � -�� � -� � � � . � deemed�e�okaa�. - . eoMw,�.�oR ..�Ponderosa_Homes No 833-2180.���� �gK�� " �, .+°`��.� vauonrior+. "' LICENSED CONTRACTORS DECLQRATIbN � - - �� � � - - � uC�� � � � I here6y affirm that fam licensed onder provisions of Chapler9 � �APDRESS SdRI@�dS dbOV2 � � �No:�3Q�34�J6 VALUATION . (commencing with Seciion 7000)Of Divislon 3 of ihe Business and � �� � - � ��� � � �� PFofessions Code,and my license is in full force and effect. CITW. - . . CLASS B � S f�� , � � 5 � T NO.OF NO.OF CHECK License Number 34345b i;� ciass B . s� STORIES FAMILIES oNe NEW � a ConfroctOr POI�IdEY�OSa HOITIGS DO}e_ - DESCRIPTION OF WORK �� � 7.�.a ' �I am exempr under Sec. � �Sl ll �2 Fdllll� Pl an 21�J4 A ADOR O FINAL ,/ � ,f #�'� ° ° ��� � 8.&P.C.for this reason � REPAIR � DATE � 7 �%" � e 5 E�.b�,� Date:� USE OF oEMOL FINAL .. . EXISTING BLDG. ❑ BY ,Y�� � o e�.j(,i L;'(j'� j Signature - � � . . � � . APPLICANT TEL . . � OWNER-BUILDER DECLARATION . � � � �PRM7 NO. , C�"�,�LA""8 G� J hereby affirm ihat I am exempt from the.Controcbr's License -� � � . Law for the following reoson(Section 7031,5,Busi,ness and ADDRE55 . � Professions C6de): -. . . -� - � PRESENT- � . . . - . _. , ��,BUILDING . . _. � . . _., . _ _ ._._ —.._— , I, qs owner of fhe property, or my employees with -qDDRESS ------ '----- . �wages as tHeir sole compensation,will do fhe work and � - � e 1 9 ��J A the strucfure is not intended or offered for sale(Section ���A��TY- � � . , � 7044,Business and Professions Code). � - MOVING TEL � � - �i,� � �, o m,� � 1,as.owner of the properfy,am�exclUsrvely.contracting CON7RAC70R NO. � with licensad contracYors to consir�ct the�project.(Ser . , � F,(��(�[j(j . tion 7044;Business and Professions�Code). -ADokeSS � � `� ' � ' REQUIRED - TOTqL SETBACK FROM E%15T. ' � � �CONSiRUCTION�LENDING AGENCY� - - .- 5ET BACK YARD HWV pttOP.LINE - WIOTN � .� `��`�����O`-� I ha�e6y affirm Yhot ihere is�a construc(ion lendmg 6gency for FRONT � � � � � � � }he performanae nf the work for which this permit.is issued -��p.L � >��j ,� � h�, � �„r,s+�� ��� . - .� ��•� ��"-��.4 (See.3097,Civ.C.j. � � - . � . . . . . �.S�ioE . . .�. , _ � - � � ��.��: Lender'sNamC POII('�PT`OSri-HQI7iPS - � . . . . . - - . � � 208� Business`Cntr Dr Trvine P:c.Fae$ �'F� �'` Pe�m;�Fae r�,�`� ,�� Lender'sqddress �- � � - . - . � n I certify ihat I have reqd[his applimiion ond state tMat the - Issu ce Fee ,�'!t..".7�e°� � � o6ove informofion is correct 1 agree to comply wifh.all�County Invessgorion Fae ��n ordinances and-State Iqws�relatin to buildm �wnsiruction, / �u :and hereby a �horize represenJati9es of ihis County ta enier - -Toral Fee (a*«l��u�e +��^' m upon Jhe abov -me- �n&d p erty-for inspecfion purposes. � - � - � a . � � +-��``� . 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