HomeMy WebLinkAbout1400 Montefino_Grading Permit or a ceriificale of Warkers'Compensal3on Insurance or a cer ��
� i 1��i��}copy thereo#(5ec. 3800, �ab. c.y COl1N1'Y 9F l�5 ANGELES BUILDlNG AtdEl SAF�TY
! Policy No. Company . '
❑ Certifiad copy is�ereby furnished. FOR APP�ICAIVT TO FILL IN ADARESS f��/.� ��• �`��t�������/��� ,����
� s�re t�� �• �l.};�'E�.��r� ���.
❑ CerEified copy is filad with the county building inspecrion qppgESS L � ,� 9 � r � �'/ �� � 10CALITY
, deparfinent, LOT BLOCK NEARES7
ppEe Applicant NVMBERS CROSS STREEi
, TRACT ut57Rl i N . MAP NO. STATE HWY. PROCESSE(l SY
' CLRTEFICA7'E OF F.X�hEP'!'IQN FRORF WORICTiRS' NUMBER
CQh4YENSATIOIV I�1SC]RAiVCC r� YES❑ NO ❑- v�-�
I4 OWI�€ER � � � a,� C C1181C YDS.
E MA€L / y/ _/ HANDI�Q: �
� (ThEs settian need not 6e [ompleTed fF ihe work involved by ADDRESS f� '%�� f�+'��' / /Y .fN%7r �� ((� s � � '
': the permii is for one hundred dollars ($100)ar less.) T��
� I cer4ify Ehat in 1he performance of 1he wark for which this per- CI7Y r ;� -- �o. � " / U5�ZONE SP�CIAL
� mii is issued, I shall nof emplay any persan in any monner so as � /' STR7E � � CON�I71�3J5 �
to become subjecE to the Warkers'Compensaiion Laws. ��GINEER J v REG.NO. �g � �
� MA1L �� � Q�
Qate Appiicant ApDR€SS �
� �t. / z �1�� � �
IQOTICL7 TO APPI,ICAIV'I':If, after making this Certificate of Ex- CITY�� � � O.�J� �.J. `:�7G � c-.7
u.i
! emption, you shau€d bacome suhject 10 1he Workers'Compen- GRADING � 7EL. FENAI BY
sation provisions of the tobor Coda,you rnust forlhwith comply �OiVTRACi R NO. QAFE �
� II �
with suc1� pro�isions or this permit shall be deamed revoked. `�
k � ADDRESS T
LlCFNSLE]CO[VTRACTORS E7EC.I.ARATION
E PRC3p05ED U5E OF GRAbEp SiT�(S} VALIDATION
I heraby affirm that I am licensed under prov3sions of Chapier 9
� (commencing with 5ection 700Q) o# D€visian 3 of ihe Business . , �
� and Professions Code,and my ficense is in full€aree and effed. � f' �' " � �
� License Plumber Lic Cfass
I '
-I �Oi1fYQCTO( �418 � '
I
� CHECK fF 511PE V15ED ADIN
; � ❑ I am exempt from !he licensing ret�uirements as I am a SIGNAFURE
� � licensed urchilect or a regislered professional engineer OF APPLICAN
acTing in my professianal capacily (5ec�ion 7051, Business A�pR� �e� T p 7� ��J�'�i
and Professions Code). 5lfRE7 8oN p 9 2 E�9 a
� Lic, or i2eg,N0. Date BONp N�• �
SURETY � a e e e � �
IHOh7E q'WNF.R-BCJiLDLR DECI,ARATIQN tpMPAA3Y
I I hereby affirm Ehat i am exempt frorri 1he ConEracror's License pATE REC'D j ° J��a �
Law for the following reoson(Seciion 7031.5, 6usiness and Pro- �IIED BY
fessions Code): CASH REC'€l pATE a ° � ��� ��
I ❑ I, as ownef Of t�t6 properly, or my employees wiEh wayas ❑E�SIT$ BY FILED
ps their sole compensa�ion,WE��do rh�Work o��a�t,e 5r���- 7M1S IS A LIMlTED TIME P��MIT D �' 1 �tl� �
� iure is noi iniended or oifered for sale (5ection 7044,
I Susiness and Professians CodeJ. qLL WORK A137HDR1ZED MUST BE COMPLETED BY
� ❑ I, as owner of fha property, am exclusively conlracting T1ME LIMIT.
with licensed conlratlors to construcf 1he proEec3 (Secfian ��
7044, Business and Professions Code). '
ICONS'I'RLJL"I'ION I,FiVD[}VG AGfiIVCY. ExTEf+lPEQ TO: �Y: /
i1 �ereby affirm 1�at there is a conslruction �ending agency for �XTENDED TO: BY: � ��
1he performance of�he work for which Ehis permit is issued{Sec.
j3997, Civ. C.). p.C. Fee$ �� �(��. � Permit Fee
{ Lender's Name � •� r
` / � - � � , Issuance Fee
Lender's Address
I certify Ifiat 1 have read lhis application and stale ihat !he �()��'��- � Qy�, `� Tolal Fee
� above informa€ion is correcF. I agree 10 comp[y wilh all County
I ordinances and 5tale laws relatfng ta building construction,ond �� � ��
� hereby aulhorize represenlatives of Ihis Couniy 10 enler upvn � �
I the above-mentioned property for inspeclion purposes. �t=E RC�[;RSE I�OI2 }:XPLANA'f'aR]' LANC�UAGl:
!
j Signalure of Permiltes Dafe ps
�