HomeMy WebLinkAboutNo Permit Number (22)WORKERS, COMPENSATION DECLARATION 76A641T
CE 807 (REV. 2-80) APPLICATION FOR GRADING PERMIT' I hereby affirm that I have a certificate of consent to self 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
15
LOCALITY
department.
1____
Date- Applicant
LOT
NUMBERS BLOCK NEAREST
CROSSSTREET _.
k.
CERTIFICATE OF EXEMPTIO& FROM WORKERS' TNRAc5TE,, 24046 DISTRINO. IMA N STATE HWY.
NSATION INSURANCE Y
This section need not be completed if the work involved OWNER CEIry T.11 -*!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 alanngi 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 77
MAIL
Date- Applicant
NT: If, after, making this Certificate ofNOTICETOAPPLICANT: 624 W 0
Exemption, you should become' subject to the Workers'
CITY ont— CL
provisions of the Labor Code. you must forth. CompensationWwith
GRADING TEL. FINLAE
comply with such provisions or this Permit shall be
NO. DAT
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 (Residentio" 9 (commencing with Section 7000) of Division 3 of the Bust-
ness and Professi4)ns Code, and my license is in full force and
effectv',",/ ,Lz- J
Licen,c Number'Lic. Class
IF SUPERVISED RADIN6CHECKG
Contr.ctptll-- Date SIGNATURE J. C 1 7 C V
am exempt from the licensing 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 Profbssions Code) - THIS IS A LIMITED TIME PERMIT
1, as owner of the property, or MY employees withF1 ff
wages as their sole compensation, will do the work ALL WORK AUTHORIZED MUST BE COMPLETED BY
and the structure is not intended or offered for sale
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 lendingling agency
the of the work for which this isperformancepermit
m issued (Sec. 3097, Civ. C.). P.C. Fire $ A/!%" Permit Poe
Lender's Name
Issuance Fee
Lender's Address
r
I certify that.] have read this application and state that the Total Fee
above information is correct. I agree to comply with all County 2 2 4,_ b IordinancesandStatelawsrelatingtobuildingconstruction,
and hereby authorize representatives of this County to enter
upoq't . lie above )Yen tinned property inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ut Permittee Date