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HomeMy WebLinkAbout1182A 4011A 1VORKIiRS'COA1PIiNSATION DCCLARAT[ON �6A64,T �. APPLICATION FOR`GRADING PERMIT �'�:. � CE 807(REV.2-80) . [ hereSy atfirm that 1 have a certificate of consent to self �in'sure,or a certificate ol Workers'Compensation Insurance,or . . � a'certified copy thereof(Sec:,3800,Lab..c.) ,.��. r / COUNTY OF LOS ANGELES - BUILDING AND SAFETY - Policy No:'� '�Company � ��� Q Certified copy is hereby furnished. FOR APPLICANT TO FILL IN S�TE „� '� �i(_;!� f ,": ; ' � ADDRESS � i ��\, � Certified copy is fiied with lhe county 6uliding inspection SITE E � �" .a 1/ LOCALITY �� department, � �,f�- j LOT _ i'` Date�" �^� Applicant � NUMBERSy� BLOCK NEAREST ��-Il i., . `�:,. .. , +'./ f r , � .; CfiOSS STREET � "�� ' � CL•'RTIFICATE OF ERE�IPTION FRO�f\VORKERS' NR MBER .. `���%� DISTRICT NO. MAP NO. 5TA7E HWY. PROCESSEO BY } COM1IYENSATION iNSURr,N�E �J fl O "�� Q OWNER f ��'�`� f'�:•'i�'C� CUBIC YDS. i y�� �� . _ U (This section neeJ not be completed if the work involved � . by the permit is fo� one hundred dollars(SI00)or IessJ MA�� '���f�� :��L�. �. . ,�,,.a:, rj�.%�"" HANOLE� J� . 1 �- t-,.�.�,�. TEL.i�7f�.���(. lL I certify that in the p�erformance of the work tor which[his CITYt..•`.:'�'' �' NO. '- ' �E ZONE SPECIAL permit is issued,I 5hail not employ any person in any manne� - STA7E CONDITIONS } so as to become�subject to the Worke�s'Compensation La�vs. ENGINEER� r��•�� ` REG.NO. � MAIL � � �• � � � Q Uate APPiicanl i'�1 r..:.. .., � ^� � NOTICE TO APPLICANT:lf,after making this Certificate of CITri `�'�' ��-' '�'� • NO�� �'a ff� ? ' � . � O � Exemption, you shouid become subject to the Norkers' " � -s Compensation provisions of the Labor Code,ynu must forth- GRADING F"�` ;;i,',f TEL. �/y��_7t�!„` FINAL ��' � �wilh�comply �vith such pmvisinns or this permit shall be NTRA TOFi ` NO. � DATE deemed�evoked. ADDRESS I�?����.+ � = y,��l` ��, �••� ��E:'��.� r LICENSCD CONTRACTORS DF.CLARATION - PROPOSED USE OF GRADED SITE(S) � VALIDATION :, , I hereby affirm that I am Iicensed under provisionsof Chapter f,4 .�:,fj•�.�.•�'-- � ; 9�commencing with Section 7000)of Division 3 of the Busi• � ness and Professions Code,and my ticense is in full force and � � effect. . - ' �',�;�'�•�� � LicenseNumberrj `:�;..�rj�� Lic.Class'� � . . � H.!,�,�,!i,1.Fi _. � r�.` �` -'}����^ CHECK IF SUPERVISE�GRA�ING � . Contractof .�. . •' �•JDate - ATUR - . /; ��;,f,�����' � - I_,�.��:: �• � , , OF APPLICANT.�.�,. ' i�..�. � . , � . . I am exempt fmm the licensing requirements as I am a �� r�5(�y�(;,(�[t��. IlcrnSed etChlteCt ar a registered prafessional engineer pDDRESS +'��U 4-��• tf"l��/iNOL ��;frf!:~( � . . � �acting in my pm(essional capaciry(Seetlon 7051, �us• � , . �'F. � inG55andProfeSSiDnSCode). � . 'SURETV$ � �' 4(, "BOND�, � �J : , �„�1,�-J�.�._-G , 80ND - NO. /'.� f':C^ . L4c.or Reg.No. Date COMPANY`�,, :��, , ' . ' ( ' ' S � , - . . �. , �,� �HOM1tE 01VNER-BUILDER DECLAI2AiION ____ �ILEO��'•�'-fi{ g�c'D „Y - � - _ ...._ ------- `- — ----- ------------------- - -- - . . . ---_ _._._ _.___.- -- -- ----- ----- --- ------ -- --- - -- ----- -n -----_ . --_. I hereby efflrm_that 1-am exempt from the ContractoPs CASM - REC'D � DATE ' � � . .}�i�t���.11 - - License Law for the following reason(Section 1031.5,8usi- DEPOSIT$ BY . FILED � •i�;�� . Iness ane rrotessions coae): THIS IS A LIMITED TIME PERMIT ' ��� �� � '❑�t, as owner of fhe property, or my employees wlih . _ '�4! �wages as lheir sole compensation, avill do �he wotk q�L WORK AUTHORIZED MUST BE COMPLETED BY ' ' �+'�� `!���� -and the structure'is not intended or offered for sale � ' � ' ' -' -� (Section 7044,6usiness and Professions Code). •���C=�+J��� " � I,as o�mer of,the property,am ezdusivNy contracting TIME LIMIT: ' " with licensed �contractors to ronstruct the project ''��r 2 r��� (Section 7044,Uusiness and Professions Code). ExTENOEo 70: sv: . � �� � CONSTItUCT10N"LIiNDING AGENCY' EXTENDED TO: BV: � I hereby�affirm that there is a construction lending agency � � � �,tor ihe perPormance of the work for which this permit is �/ � ' _ . . ' issued(Sec.3097,Civ.CJ. P.C.Fee S '7�''.<<� Permit Fee "� S• � � . . � LendeYs Name , . �� \ � � �.�t r`�1;: �'u. �'�� Issvance Fee /C: .) :i - Lender's Address � � � -t certi(y that 1 have rcad this appiication and SIBIC 1h81 II1C �L�C%,��Z' Total Fee ' �-%_•5 �� � � � . above informalion is correct.[a6ree to comply with all Cuunty , i"ordinances and State laws relating to building conetruc[ion, �.;�•�`�(q �,� . � . - und heteby authorixe�rep�esdntatives af this County to eme[ � upon ttfe above.mr(ifiLBCd proper[y for inspection purpnses. SF.E REVERSE FOR EXPLANATORY LANGUAGE � � ' . , " J . Y� :J f/�> . . ',{ . 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