HomeMy WebLinkAbout9724A 5448A1-OR111 RS' COSIPI'_NSA 110% DfCLARA-I ION;
tfem that I have a certificate of consent to self insure,
icate of Workers' Compensation Insurance, or a eer-
y thereof (Sec. 3000, Lob. C.)
Company
ified cony is hereby furnished.
Wied copy is filed wilh the county building inspection
or lment,
Applicant
FRTIFICA n? OF FXFSIPTION FROM %%'OItK[:RS'
COSLPhNSA'II W IN.M.'RANCIE
action need not be completed if the work involved by
rmit Is for one hundred dollars ($100) or less.)
y that in the. performance of the work for which this per -
issued, I sholl not employ any person in any manner so as
ome subject to thn Workers' Compensation Laws.
Applicant
ICF TO APPIACA\T: If, after making this Certificate of Ex-
mn, you should become. subject to the Workers' Compen-
n provisions of the Labor Code., yolt must forthwilI, ca—ply
such provisions or this permit shall be deemed revoked.
I.ICI'\SI•I) CONTRACTORS DIXA.AHAI [ON
reby affirm that I am licensed under provisions of Chapter 9
nmencinq with Section 7000) of Division 3 of the Business
I Professions Code, and my license is in full farce and effect.
anse Number Lic. Class
ntractor Dote _
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Business
and Professions Code).
ic. or Re.g. No. Date
IIOSf Ii OWNER -BUILDER DFCLARA I]ON
I hereby affirm that I am exempt from the Contractor s license
Low for the following reason (Section 7031.5, Business and Pro-
fessions Code): _
I, as owner of the proprtrty, or my e.mployees with wages
as their sole compensation'vvLR-do the work and the struc-
ture is not intended or offered for sale (Section 7044,
Business and Professions Code).
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Section
7044, Business and Professions Code).
COSI RUC "I ION' I.I NDING AGENCY
I hereby affirm that there is a construction lendin2ogency for
the performance. of the work for which this permit is issued (Sec.
3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and sate that the
above information is correct. I agree to comply with all Couniy
ordinances and Sto'e laws relating to building construction, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes.
Signature of Permittee Date '
76n07 APPLICATION FOR GRADING PERMITCEB.',7 rPFV. Z BO) IOrPD ,
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN SITEADDRESS y'. :
S'TEADDRESS LOCALITY
LOTNUVEIERS BLOCK NEARESTCROSSSTREET t
L RAC:
7 } NUMBER ,[, 'J 3 D'STP'Ci NU
I
MAP NO,
rC r7 r
SEATE HWY. PROCESSED BY
YES NO• L'
OWNER CUB!C YDS.
HANDIED.
f
MAILADORESS 1
CITY NO. USE ZONE SFfCIAL
CONDITIONSSTATE
ENGINEER t REG. NO. '
MAILADDRESS ` -
IEL. r
CITY NO.
GRADING TEL.
CONTRACTOR NO FINALDATE BY
ADDRESS
PROPOSED USE OF GRADED SITE(S) VALIDATION
I' •, /. •s • r: [ ..
rA
CHECK IF SUPERVISED GRADING
SIGNATURE
OF AFPI ICANT
TEL.
ADDRESS NO.
SURETY S BOND
BOND NO.
SURETYCOUPANY
DATE RECD
FILED BY
CASH RECD DATE
DEPOWS BY FILED
THIS IS A LIMITED TIME PERMIT
ALL WORK AUTHORIZED MUST BE COMPLETED BY
TIME LIMIT:
EXTENDED TO: BY:
EXTENDED TO: BY:
P.C. Fee E 1 Permit Fee
Issuance Fee
Total Fee ,I ,.
SI:1: REXIERS17 FOR FXIII.ANATORY I,A\GUAGr