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HomeMy WebLinkAbout20210518163251243.pdf.pdfb [' it COMPENSATION DECLARATIO3V C12 807 T APPLICATION FOR GRADING PERMIT 1CEso7IREV.2 t301 I 1 hereby affirm that I have a certificate of consent to self Insure, c,r a certificate of Workers' Coill pensa(ion ["urance, or I a certified copy thereor(See. 3800, Lab. C.) COUNTY OF LOS ANGELES ' I Policy No. Company t ! Certified copy is hereby furnished. + FOR APPLICANT TO FILL IN I' SIET t Certified copy is tiled with the county building Inspection . 3,00 GtCO ul rOC tr department,$ -- ILOT I Date Applicant NUMBERS l•© 13LOCK y C LItTII-'ICATF.OI EXEMPTION FROM WORKERS' TRAC-r rp COMIIENSATION INSURANCE NUMBER IQ 5 77 ,t .+ i OWNER Y%IrJRKARTl7NI 00+11KI) i. (This section need not be completed if the work, Involved BUILDING AND SAFETY AiDDRESS LJ0 t LDGALITYNT J—C J CV 1! by the permit is for one hundred dollars ($100); or less.) MAIL c 1,; Cti/ 'r, N 7-iq hf o rt I I; 1, certify that in rite performance of the work for which this CITY QT IMd N tJ l3 'RNnL(?/k)zt61_ pertnit is issued, I shall not employ any person In. any, inanner 1 i so as to become subject to the Workers' Compensation Laws.,' ENGINEER PIMA H I-:- !' Date'' Applicant -, --- `•,_ MAIL 6,*7 6 e,I i, I, NOTICC TO APPLICANT: If, after making this Certific8le'of.''.! CITY COO AM lixemption, youshouldbecomesubjecttotheWorkersCompensationprovisions of the Labor Code, you must forth- GRADING with comply with: such provisions- or this permit ,shall be CONTRACTOR TE NO. G11z N 4 L. NEARFST \\ 1it(,.\ Cf1QSS:; 7F11_E_ 7__ 13-- V&U) DISTR16- NO. AP NO. STATE HWY, PROCESSED BY i )i cNOV I CU131C'eDS, HANDLED; r USE ZONE SP CIAL e . C NDITIONS 794_Qt5 deemed revoked. ADDRESS LICENSED CONTRACTORS DECLARATION I1. PROPOSED USEOF GRADED SITES) I hereby affirm that I am licensed under provisions of Chapter ., 1+fr 1. 4 (eornmenciug with Section 7000) of Division 3 of the Bust- 2 1= I2M .7- i e&,c-/^ - IaoilS e Iltess and Proressions Code, and my license is in full force and terfect. I . j r . IX. lcense Number Llc, Class Dote CHECK IF 4UPEf{ViSEO GRADING II I OF APt'LICAN7' j tj(Qif f r Iwfl111 i"iRICA C? 1 am exempt from the licensing requirements us I am a TEE./ j".. licensed architectoraregisteredprofessionalengineerADDRESS %104P TINT/48 0,9N0.C/lr L/.QQd1!' acting in my professional capacity (Section 7051, Bug - mess and Professions Coda). SURETY $ BOND a' I; BOND NO. Lie, or Reg. No. Date SURETY COMPANY fiOMF OWNER - BUILDER DECLARATION DATE REC'D 1„ FILED BY 14 hereby affirm that I am exempt from the Contractor's CASH REC'D DATE License Low for the following reason (Section 7031.5, Busk DEPOSIT$ BY FILED mess and i' rofcssions Cod* i I 1, as owner of the properly, or nay cinployees Willi THIS IS A LIMITED TIME PERMIT_ T wages a-, their sole contpensatloit, ,will do the work ALL WORK AUTHORIZED MUST BE COMPLETED BY and tttc ,structureIsnotintendedoroffered ;for sale 1 (Section 7044, liuslness and Professions Code). ITIME LIMIT: ^ -- 1, as owner of the property, atn exclusively contracting with licensed contractors ( o construct the project EXTFNDED TO: BY: Section 7044, 13usincssandProfessionsCade). CONSTRUCTION LENDING AGENCY I' {' r EXTENDED TO: BY; I hereby affirmtha1thereisaconstructionlendingagency'. x for lire performance Lof the work for whicit this permit Is I Issued (Scc..1097. Civ. C.). P.C. Fee $ 1_VkA.- unlit Felt Leader's Name ---- Issuance Fen 1rt'` t. '1 [I C['5 Airdress ._,---...-.-.--•..• -. _ I certify that 1 have read this application and state that tits Total Fee above informallon is correct I agree to comply with till County — ordinances and State laws relating to building construction, amE hereby ;ttithorize representatives of this County to enter 4 upon Ibe above•meniloncd property for Inspection pi€tpuses. SEE ItEV1.;RSE FOR 1sXhLANATORY LANGUAGE 1 Signature of Pormittee Date It FINAL HY i DATE i€t S VALIDATION 7 5 2 7 A t•445OO 44 00r' OS09-- Siff