HomeMy WebLinkAboutNo Permit Number (62)L'OR111 RS' COSIPI'_NSA 110% DfCLARA'I ION;
tfirm that I have a certificate of consent to self insure,
icole 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 budding inspection
or lment,
Applicant
FRTIFIC.q'l'I! OF FXRtIPTION FROM LyOitK[:RS'
COSIPhNSA'l I 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 -
ma, you should become subject to the Workers' Compen-
n provisions of the Labor Code., you must forlhwilI, cc^p!y
such provisions or this permit shall be deemed revoked.
I.ICI'\SI•I) C,ONTRACI.ORS DECLARA I [ON
reby affirm that I am licensed under provisions of Chapter 9
nmencinq with Section 7000) of Division 3 of the Business
1 Professions Code, and my license, is in full farce and affecl.
anse Number Lic. Class
ntraclor 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 Reg. No. Date
IIOSIIi 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.
I.ssions Code): _
I, as owner of the property, or my e. n,plbyees 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 properly, am exclusively contracting
with licensed contractors to construct the project (Section
7044, Business and Professions Code).
COSI RUC "I ION LENDING AGENCY
I hereby affirm that there is o construction leodinaogtlney 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 hove read this application and state that the
above information is correct. I agree to comply with all Couniy
ordinances and Stole laws relating to building construction, and
hereby authorize representatives of This County to enter upon
the above-mentioned property for inspection purposes.
Signature of Permiltee Dote '
76n07fPFv. Z BO) TD BDf..^,7CE rAPPLICATION FOR GRADING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN SITEADDRESS f'. :
S'TEADDRESS LOCALITY
LOTNUVEIERS BLOCK NEARESTCROSSSTREET If
LRAC:
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
MAILADDRESS 1
CITY NO. USE ZONE SFfCIAL
CONDITIONSSTATE
ENGINEER I REG. NO. '
At,AIL ` ADDRESS ` -
IEL. r
CITY NO.
GRADING TEL.
CONTRACTOR NO FINALDATE BY
ADDRESS
PROPOSED USE OF GRADED SITE(S) VALIDATION
I' •, /. •r • r: G. .+
CHECK IF SUPERVISED GRADING
SIGNATURE
OF AFPI ICANT
TEL.
ADDRESS NO.
SURETY S BOND
BOND NO.
SURETYCOUPANY
DATE RECD
FILED BY
CASH RECD DATE
CEPOS!TE BY FRED
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 ,.
SI717 REXIERS17 FOR FXI'LANATORY I.ANGUAG1i