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HomeMy WebLinkAbout0859B (6) WORKERS'COAfPNNSA'CIOYDHCLARA'1'!ON �yqyq�T I hereby affirm ihal I hove o certificate of consen�to self insure, CE 807(REV.Z-80�10/80 APPIICATION FOR GRADING PERMIi' or a certiftcate of Workers'Compensotion Insurance,or a cer- � � tifiad copy therevf(Sec.380D,Lab.C.) CWNTY OF LOS ANGELES BUIIDING AND SAFETY Policy No. Company ❑Certified�opy is hereby furnished: FOR APPLICANT TO ADORESS a o���� �Q SITE i , ❑ Certified copy is filed with the county building inspecfion qppg� LOCALITV ��Q��y� �Q�/� department. �pT \ �'� Dafe ApPlicont NUMBER5 B��K CROSSSTREETSQ w� Gh SQ� r� TRACT CERTIFICA7'E OP EXEAfPTiON FROM WORKERS' '? Nt1M8ER v ��Tp �� MAP NO. ST HWY. PROCESSED BY COMPENSATION INSURANCE J a �Q 1,7�� YES❑ NO OWNER /"- CUBIC D5. (T61a wcfion naad nol 6a complatod K Nw work involv�d by ��� • �� HANDLED: � � fho pormit is for ono hundrod dollars(;100)or IQss.) ADDRESS� 1, �� � , . L. I certify thal io fhe performance of the work for which this per- GTY� NO. � � USE 20NE SPECIAL mit is issued,I Shqll no1 employ ony person in any manner so as STATE CONDITIONS Y- to become subject to the Workers'Compensation Lpws. ENGINEER REG.NO. O ^^^u v Date Applicanf ADDRESS o�• TEL. � NOTICE TO APPLICANT:ff,after moking this Certificate of Ez- ��Ty, ,�7 � � emption,you ahould betome wbject to the Workers'Compen- GRAOING ��, �a w sation provisions of the Labor Code,you must forthwith comply ConirRAC70R NO. F��� BY a with such provisions or�his permit sholl 6e deemed revoked. DATE fn z LICENSED WhTRACTORS DF.CI.ARATFON ADDRES'' I here6y affirm that I am licensed u�der p�o�isions of Chapter 9 PROP05ED USE OF GRADED SITE(S) VAIIDATION (commencing with Section 7000}of Division 3 of the Business and Professions Code,and my license is in full farce and effect. license N�mber Lic.Class :=0 8` -�,; Contrador Date CHECK ff SUPERVISED GRADING � '{(• • • • I � ❑ t am exempr from rhe licensing requirements os I am a SIGNATURE � � licensed orchitecf or o registered profeuional engineer OF APPIICANT • � •� I �.I�V � acfing in my professionol capacily(Sedion 7051,Business qpDRESS TEL. �� `. and Professiom Code). � N�� • 4.) . „, � SURETY S BOND lic.wReg.No. Date BOND NO. � (;",�C—"S? HOME OWNFR-AUILUER llFC1,ARA'1'ION SURETY f he�eby affirm ihat I am exempt from ihe Confrador's License COMPnnIY Law for Ihe following ieoson(Section 7031.5,Business and Pro- �A� REC'D FILEO 8Y fe55ions COde): �H REC"� DATE � ❑ 1,as ow�er of ihe proper�y,or my employees with wages ���T 8 BY ftLEO as their sole compensar�an,wi�l do rhe work and the struc- THIS IS A LIMITED TIME PERMIT ture is nat intended ar offered for sale (Section 7044, BVSiness ond Pfofessio�s Code). qLL WORK AUTHORIZED MUST BE COMPLETED BY ❑ I, m owner af the property, am exclusively contractinq TIME IIMIT: with licensed contractors ro constr�U ihe project(Section 7W4,Business and Prafessions Code). CONSTRUC'PION I.FNDING AGF:NCY EXTENOED TO: , BY: � I hereby affirm that there is a consiruction lending agency for ihe parfwmance of the work for which this permit is issued(Sec. EXTENDED TO: BY: 3097,Civ.C.). � p,C.Fea b � � Permit Fee lenders Name y� Lender's Address �V Iss�once Fee I certify ihat I have read this opplication and state ihot the a'��l q a Total Fee � a6ove informafion is corred.I ogree 10 comply with oll County ordinpnces and Sta1e laws relating to building consiruction,and �� � ��5 � hereby authorize represenmtives of this Counly to enler upon � � ihe above-mentioned property for inspedion purposes. SF,F:RF,VF,RSE FOR EXPLANATORY LANGUAGF SignaWre of Permittee Date rDa���� �O�`N �� � f � N O�y�rs p� � ��� �Cyw V� �O w �,~ � n�,� �r� V � � � a � f G � ti' Q`'3 C. ? 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