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HomeMy WebLinkAboutNo Permit Number WORKGRS'CO�IPENSATIONDECLARATION 76A641T app�ICATION FOR GRADING PERMIT � CE 807(R E V.2-807 � I hereby affirm that 1 have a certificate oP consent to self insurc,or a certificate of 1Vorkers'Compensation'Insurnnce,Pr• � - e certified copy th reot(Sec.y,38 0�,J.ab.C.) "ri_ �f COUNTY OF LOS ANGELES BUILOING AND SAFETY Polity NoN�'°�"��C6iiipnn�/}'/ � �ii��.�/'!-�:�5,-� '� � 'Certitied copy is hereby comished. � nFOR APPLICANT TO FILL IN SITE -����,��C) ;= l �t:.�r+LL�!� `,,C� :Z{�.. aooaess ' (.. � ~._ SITE f"fll..L_•v�,• r 1 l..f� �.:�. �. ,...,....� -. . . Certified copY is filed with the countY buildin8 inspec�n '.',��d:�.-.�. ..l-_f ti..S:r�b=:....Y:.�U�*.��� ! LOCALITY �%f^�r'T��}���' t�'!�_� depar[4n �t. i ..-.....;� :.".p Lr.U:, . t.:u Date'���'�f�'� APFI'icanl lCVMBERS 2 BLOCK NRARESTREE f" eG.'� r-�r� �"�; .�.':` �� � . CERTIFICATE Or EXEAIPTION�RO�i WORKERS' TFACT PP'I 15513 I NO. MAP NO. STATE HWV. PROCESSEO BV/ } NUMeER �� ' C0�1PEN5ATIDN INSURANCE 2/ i V ❑ � 4' owNea �rcicro nnd Sons c �c vos.. � ;.(This section nccJ not be compieted if the �vork involved HANOLEO: U .�by the permit is for one hundced dollars (5100)or IessJ MA�� �5� I7. Tl1EtlI1 AVCIIUE ���4$0 � w J I certify that in the yerformnnce of the�vork for which thfs CITY�hFIhC1II1 �ZQ�7 No��71A /G32-0134 tt lSEZONE SPECIA� permit is Issued,1 shall not employ any person in any manner Ana $C li� d STATE 33503 CONDITIONS . � �so as[o��A/ecome subjeCt to the 1Vorkers',Compensation.Ynws. ENGINEER pEG.NO. �,.!'. ..✓�%� . ' . ' MAIL 17�82 $�:}' ��2'jG Pi1VC2. Q �Uata �� ... pPPlicant ,�:�. -� ':' :��r,. _.. . � � !L NOTICE TO APPLICAN7:If,after making this Ce+tificate of C�T�,ITV�RC 92714 NEbL.�1�7 261-22ZL �, � 'Exemption, ynu should become subject to the R'orkers' a �Compensation provisions of the La6or Code,you must forth- GRADING iiOt SCZCCCCaTE�. FINAL . BY y�j �wi[h compty wi[h such provisions or this permit shall be N FA 7 R NO. OATE : F >.deemed revoked. � - ADDRE55 � ' LICF:NS�D CONTILACTORS DtiCLARA710N pROPOSED USE OF GRADED SITE(S) I VALI�ATIOnI ;I hereby affirm that I am licensed under provisions of Chapter �A �Sr" tl --� '�, � � 9 (commencing with Section 7000)of Division 3 of the Busi- ; , Tess and Professions Code,and my license is in full force and F.COPy U R'b' �, effecL d ' !'�-'�' " I �`�FY e`j' t;j I ':...,,-,�,. , ;Licensr Number Lic CIas3 - � ` � �!�!'l� piECK IF SUPERVISE�GRADING .�� ��� = I y+ �Contractor- :�! .;:' �t:�,{:Da[e''�'�• ' 1 ATUR '. ���/ � � =��•-•!�f-� �� OF APPLICANT.',.%�i - A✓C%�AJ1 i ,, � .. : � y 1 . .. • � I am e empt from the licensing requirements as I am a , � TE�sy�/� c �� � � � � . licensed architect or a registered professional engineer •� �!"I , '� � •"� _ . ADDRESS=✓�:•.�v..i��<�r..Gr• NO.1/I�l 'L..L . ' .,... acting in my professional capacity (Section 9051,Du5- , ' . , �� ' inessandYrofessionsCode). BONDYg �n��F'�-'�' NONJ.:� n//���'.^t� ��[� ,( ��7? r� �Lic.or Reg.No. Date SURETV :',;�., r y �';"{,h � ,� _ . ,��i� , ��,i�7 2.r'.C�O�s', COMPANY /�Y��„S'`��"'"'" (� J.!Y�C+ �..- . � �. . ' HOb1E0\VNER•BUILDER�ECLARATION pILE�iLs'r% 1 C%��BVC'D • `^t•y , . . (J�;;j�I"�� :.+.i♦ ��I hereby atfirm that 1 am exempt Gom the Contractor's CASH REC'D oaTE � �License Law for the following reason(Section 7031.5.Busi• DEPOSIT$ BY FILED � ness an�Yrotessions Code): THIS IS A LIMITED TIME PERMIT ,i..ft.��7.�,F � 1, as owner of thr property, or my Ployees with � ,� , , wages as their sole compensation, will do the �vork ALL WORK AUTHORIZED MUST 6E COMPLETED BY � �i,!,};�i J,�,�!, ' und the ttruc[ure i5 noi in[ended or offered !or sale . ' (Sectlon 704a,Uusiness and Pro(essions Code). � �TIME LIMIT• '� �� . �C � 1,as owner of the property,am exclusivelY contracting � �, ' ��'��'G'{�S"��`'- ith licensed contractors to construct the project EXTENOED TO: BY: �� r ����;0,F'[1`, � (Section 7044,Dusiness and Professions Code). � • � � � � CONSTRUCTION LLNDINL'AGL'NCY EXTENDED TO: BV: • ' . . I hereby affirm ihat there-is a construction lending-agency � •�����"� �����` for the performance of [he work for u•hich this permit is �7 '�;-�. � issued(Sec.J097,Civ.C.). P.0.Fee S ��� / Z'� Permit Fee (;,j .(���' � �- LendePs Name -� � Ld/Lf/t �Z 0 Issuance Fee ��a' _,1{ ��J� ��.� Lender's Address �f j�1 / �n �G'i!/L ��7'� Totai Fec /l/47� � J�J �.-��'��\ 1 certify [ha[ 1 havr read [his application and stute that the > y-' ' above Information is correct.f agrec lu compl y with nll C�unty ([.��J��,N�+ � ordin:mces and S[ute laws rela[ing to yuilding mnsiruction, r����� V�! 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