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WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self
assure, or a certificate of Workers' Compensation Insurance, or
I certified copy thereof (Sec. 3800, Lab. C.)
iolicy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
department.
date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved
by the permit is for one hundred dollars ($100),. or less.)
�1
I certify that in the performance of the work for which this
permit is issued, I shall not employ any p8rson in any anner
so as to become subject to the WoAdrspensatioti Laws.
Date Applicant
NOTICE TO APPLICANT: It, after making-,thas"'Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number Lie. Class
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lie- or Reg. No
Date
HOME OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work
and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code).
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to ¢uilding construction,
and Vreby authorize representatives of this County to enter
upou�the above-mentioned property for inspection purposes.
Signature of Permittee Date
76P.G41T APPLICATION FOR GRADING PERMIT _
CE 807 (RFV. 2-80)
� r ,
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
SITE
ADDRESS
SITE
ADDRESS
LOCALITY
LOT
NUMBERS BLOCK
NEAREST
CROSS STREET
TRACT
NUMBER
DISTRICT NO. MAP NO. STATE HWY. I PROCESSED BY
YES NOQ
CUBIC YDS.
HANDLED: `r
-
OWNER
MAIL
ADDRESS
TE L.
CITY NO.
USE ZONE
SPECIAL
CONDITIONS
STATE
ENGINEER REG. NO.
MAIL
ADDRESS
TE L.
CITY NO.
GRADING TEL.
CONTRACTOR NO.
FINAL BY
DATE
ADDRESS
VALIDATION
°
-
'
PROPOSED USE OF GRADED SITE(S)
CHECK IF SUPERVISED GRADING ❑
SIGNATURE
OF APPLICANT
TEL.
ADDRESS NO.
SURETY $ BOND
BOND NO.
SURETY
COMPANY
DATE RECD
FILED BY
CASH -- _ /. .'-'REC'D DATE
DEPOSIT$ BY FILED
THIS IS A LIMITED TIME: PERMIT
ALL WORK AUTHORIZED MUST BE COMPLETED BY
TIME LIMIT:
EXTENDED TO: BY:
EXTENDED TO: BY:
P.C. Fee $
Permit Fee
Issuance Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE