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 ��
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