HomeMy WebLinkAbout0154A 1121A 1122AWORKERS, COMPENSATION DECLARATION 76A641T
CE 807 (REV. 2-80) APPLICATION FOR GRADING PERMITIherebyaffirmthatIhaveacertificateofconsenttoself MinsureoracertificateofWorkers' Compensation Insurance, or
a certified C.4edcopythereof (Sec. 3800, Lab. - .y - COUNTY OF LOS ANGELES FUILDING. AND SAFETY -
Policy No.- Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE
ADDRESS
Certified copy is filed with the county building inspection SITE RES LO CALITY
department.
Date- Applicant NUMBERS BLOCK NEAREST
CRO SSSTREET
CERTIFICATE OF EXEMPTIO& FROM WORKERS' TNRAc5TE,, 24046 DISTRINO. IMA N STATE HWV.
COMPENSATION INSURANCE Y
This section need not be completed if the work involved OWNER CEIry T.i1-*!1.q P_f, lix CUBIC YDS.
HANDLED:
C
by the is for one hundred dollars ($100) or less.) A 24030 qhni-gtin T,ann, permit AMNLREss J
I certify that in the performance of the work for which this
TE L.
CITY - Ili alannij Bar NO. _ USE ZONE SPECIAL
LL
permit is issued, I shalf not employ any person in any manner STATE CONDITIONS
so as to become subject to the Workers' Compensation Laws. ENGINEER REG. NO. 12L,!77
MAIL
Date- Applicant CL
NT: If, afterI., making this Certificate ofNOTICETOAPPLICANT: 624 West 0
Exemption, you should become' subject to the Workers'
CITY Nont— CL
provisions of the Labor Code, you must forth. CompensationWwith
GRADING TEL. NO. FINLDATAE
comply with such provisions or this Permit shall be
deemed revoked. ADDRESS `4 1
LICENSED CONTRACTORS DECLARATION
PROPOSE Q USE OF GRADED SITE(S) VALIDATION
I hereby affirm that .1 am licensed under provisions of Chapter Private alrage (Residentin" 9 (commencing with Section 7000) of Division 3 of the Bust-
ness and Professi4)ns Code, and my license is in full force and
effect,",",-- -- -_, / ,q- J
License Number'Lic. Class
CHECK IF SUPERVISED RADIN6GContriictptll'F'-- DateJ. SIGNATURE C 1 7 C
am requirements as I am aT
OF APPLIC.Ny .
licensed architect or a registered professional engineer EL.
ADDRESS - NO.
acting. in my professional capacity (Section 7051, Bus-
iness and Professions Code). SURETY $ BONE)
BOND NO.
Lic. or Reg. No. Date SURETYCOMPANY
HOME OWNER -BUILDER DECLARATION
FIDATE
REYC'D
LED B
I hereby affirm that I am exempt from the Contractor's CASH RECD DATE
License Lawfor the following reason (Section 7031.5, Busi- DEPOSIT $ BY FILED
ness and Profbgsions Code) - THIS IS A LIMITED TIME PERMIT
1, as owner of the property, or MY employees withF1
wages their sole compensation, will do the worka' AUTHORIZED MUST BE COMPLETED BYALLWORKAU
and the structure is not intended or offered for salea
Section 7044, Business and Professions Code).
I
TIME LIMIT: Iri1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project EXTENDED TO: BY:
Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY EXTENDED TO:BY: 1 .1 r2 A
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
m issued (Sec. 3097, Civ. C.). P. C. Fe. $ A Permit Poe
Lender's Name.1 k Issuance Fee
Lender's Address
J I 4.b G F. -µ`- I certify that.] have read this application and state that the Total Fee
above information is correct. I agree to comply with all County2 2 4 _6 IordinancesandStatelawsrelatingtobuildingconstruction,
and hereby authorize representatives of this County to enter
upon't . mIeabove )Yen tinned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date