HomeMy WebLinkAbout4707AWORKERS'COMPENSATION DECLARATION 76A641T
CE 807 1 REV. 2-80)
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
ace
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Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
depart ment-
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness an P ofessions Code, and my license is in full force and
effect
License Num r Lic- Class
Gj
Con tracLate !
0 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, Bus-
iness and Professions Code).
Lic. or Reg. No. Date
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
f, as owner of the property, or my employees with
wages as their sole compensation, will do the work
and the ructure is not intended or offered for sale
Section 70st44, Business and Professions Code).
as owner of the property, am exclusively contracting
with licensed contractors to construct the project
Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued SSec. 3097, Civ. C.).
Lender s Name
Lender's Address
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize re sentatives of this County to enter
upon above-menY d property for inspejo urp
Sifirwilre of P'fnitteDate
APPLICATION FOR GRADING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
SEE REVERSE FOR EXPLANATORY LANGUAGE
SITEFORAPPLICANTTOFILLINDDRESS 30 1'-, v`.
SITEy- D r
E C?v LOCALITY
NUMBERS BLOCK NEAREST eek
CROSSSTREET
TRACT
N MBER
D45Tp{ /I%C(T NO. MAP NO. 5TATE HWY.
3`IS YES EI
P ED BY
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OWNER CUBICYDSHANDLED: HAND. MAIL
ADDRESS
TEL. .1.
USE ZONE SPECIAL
CONDITIONS
CITY / NO. `r r
STATE
ENGINEER REG.NO.
MAIL
TEL.
CITY NO.
GRADING TEL. FINAL BY
CONTRACTOR NO. DATE
ADDRESS
VALIDATIONPOSEDUSEOFGRADEDSITE(S)
C
CHECK IF SUPERVISEP GRADIN
SIGNATURE
OF APPLICANT
TEL. i IADQtNO. J
SURETY $ BOND
BOND NO.
SURETYCOMPANY
DATE RECD
FILED BY
CASH RECD DATE
DEPOSIT $ BY FILED
z 4 % Q % ATHISISALIMITEDTIMEPERMIT
4 a a a a 4ALLWORKAUTHORIZEDMUSTBECOMPLETEDBY
7 0 5 0TIMELIMIT:
a s a 7 G 5 0 3EXTENDEDTO: BY:
07.24-84EXTENDEDTO: BY:
P.C. Fee $ Permit Fee QO
Issuance Fee S
n
Total Fee 1
SEE REVERSE FOR EXPLANATORY LANGUAGE
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