HomeMy WebLinkAbout20211013122332419 (17).pdf.pdfWORKERS' COMPENSATION DECLARATION
hereby affirm that I have r lei ifi tco en •„ elfinsure, itYtiun CE 807 (REV.2-80)I CE 807
T
I r rON FOR GRADING PERMIT
or a certificate'ofWor rs teI su eor
a certified copy thereof (Sec. a C.) COUNTY OF LOS ANGELES BUILDING AND SAFETYPolicyNo. Com—m
Certified copy i Avf FOR APPLICANT TO FILL IN SITE @+
ADDRESS
Certified cop. fi o ' l uiliUn'spectL
department. SITSADDRESS A 00 C-ke) W 0-00 1C L_AJ
LOCALITY Ck_"xfLti0,Y`L
Date ' Applicant
LT
NUMBERS O O BLOCK NEAREST a
CROSSSTREET CERTIFICATEOFEXEMPTIONFROMWORKERS' COMPENSATION
INSURANCE TRACT
NUMBER
2 7 SAP NO. STATE HWY. PROCESSED BY This
section need not be completed if the work involved OWNER l%l} R !` i 1 /'/'% ('® (1 YES
O HANDLED:
bthepermitisforonehundreddollars $100 or less. YP ( ) ) MAIL' i ADDRESS
1-80 7-T-"T^H 0.17I
certify that in the performance of the work for which this CITY OZ J4M /V ) 64QNO 7Iq) 161-07/- permitisissued, I shall not employ any person in any m nee so
as to become subject to the Wor ers'`Compensat4o aws. 1STATE ENGINEER !'/
illi %Y 7 REG. NO. USE
ZONE SP CIAL C
NDITIONS r
e Date,
3 30 Applicant C s, MADOREIS ® %»
lit Z•,5 CeP,<0 ' NOTICE
TO APPLICANT: er making thi ertificate of Exemption,
you should b c me subject t the Workers'_ CITY A% C' NO %/ff 7/—=% Compensation
provisions of the Labor Code, you must forth- with
GRADING
TE 7 J CONTRACTOR
IY/" 0? FINAL BY complywithsuchpYprovisionsorthispermitshall. be NO. // DATE deemed
revoked. ADDRESS
ON/' ""/I %%4 91 LICENSEDCONTRACTORSDECLARATIONPROPOSED
USE OF GRADED SITE(S) VALIDATION I
hereby affirm that I am licensed under provisions of Chapter 9 (
commencing with Section 7000) of Division 3 of the Busi- SJ..N ,., ,, ness
and Professions Code, and my license is in full force and 7 % effect. License,
Number Lic. Class a 1 Contractor
Date CHECK IF SUPERVISED GRADING I
am exempt from the licensing SIGNATURE
OF
APPLICANT 1 ,e 4 4 5 Q Q requirements
as I am a licensed
architect or a registered gprofessional engineer in
my TE
t . ADDRESSf8ttfIA0TELe)lJ'1"J,%CeQjj' I4 5; Q
Q acting professional capacity (
Section;7051, Bus- iness and Professions
Code). ' j 'rRAMM 0 5, Q Q ®j j BOND r t7
NO. • 02 Lic. or Reg.
No. Date 7 Ci 5,
2 A HOME OWNER -BUILDER
DECLARATION DATE REC'D FILED, BY I
hereby affirm
that I am exempt from the Contractor's CASH D License Law for
the following reason (Section 7031.5, Busi- DEPOSIT $ BYC FILED 2f® 1 1 12 1 ness and ProfessionsCode): I, as owner
of the property, or my employees with THIS IS A LIMITED TIME PERMIT 1 1 1 i ' wages as theirsolecotintendedor11erthe
work and the .structure
is not intended or offered for sale ALL WORK AUTHORIZED MUST BE COMPLETED BY 1 - Section 7044, BusinessandProfessionsCode). I, as owner
of the property, am exclusively contracting TIME LIMIT' with licensed contractors
to construct the project Section 7044, Business
and Professions Code). EXTENDED TO: BY: CONSTRUCTION LENDING AGENCY
I hereby affirm
that there is a construction lending agency EXTENDED TO: BY: e L! for the performance
of the work for which this permit is issued (Sec . 3097, Civ. C.). Lender's Name
P.C. Fee $
PermitFee , r c J
L?,
Lender's Address
1 / a f
l , o)_s Issuance Fee I certify that .
I have read this application and state that the Total Fee0, "Z 83 o r-, C r, above :information is correct. 1 agree to comply with all County ordinances and State laws
relating to building construction,'a\ A and hereby authorizeresentatives
of this County to enter upo h e- e
ti d property for inspeon p ses. SEE REVERSE FOR EXPLANATORY LANGUAGE"ot' e of Per
ittee
Date