HomeMy Public PortalAbout4504TEMPLE CITY BLVD_Grading WORKERS COMPENSATION DECLARATION APPLICATION FOR GRADING PERMIT
CE 80 (REV
I hereby affirm that 1 have a certificate of consent to self CE 80
7 Z 80)
inure or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING 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 Gy i J' LOCALITY
department
LOT
Date Applicant NUMBERS S BLOCK
NEAREST f QWb r`,fA
' OSSSTREET
CERTIFICATE OF EXEMPTION FROM WORKERS TRACT /a TfN7 .>' k ��� S. DL4TFUCi2 M NO STATE HVY1' PROCESSED BY }
COMPENSATION INSURANCE N MBER J s,y/' .7YES tNO 2 tl
(This section need not be completed if the work involved OWNER O!�%J F CC/�itt �•lpf�+y.r/ �jvG CUBIC YDS
d MAIL / HANDLED / V
by the permit is for one hurt red dollars (SI00) or leu) �Q8-Ala LfJli, 1 Wa �,{ / Cell I- f( ` J
/ c ] GJgt
I certify that in the performance of the work for which this ITV NOV`�s/ �� ?-
permit Is issued I shall not employ any person any manner 115E ZONE SPECIAL
m
so as to become subject to the Workers' Compensation Laws ENGINEER S�i1r.S7v f .CIOC REGI NO �lJ3oU CONDITIONS - y
2
Date Applicant MAIL J(•g7.N //6N Q
/ EE ��ll 2
NOTICE TO APPLICANT if after making ibis Certificate of CITU Y� (w«.s/b . /y NO 7(1 �'��
Exemption you should become subject to the Workers 2
Compensation provisions of the Labor Code you must forth GRADING �y / )G�
CTORQu/JJG/le fJ T J��/ DATE
W
with comply with such provisions or this permit shall be r-fj(F/I� BV F
NTRA
deemed revoked ADDRESS Ir e V t /
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITEI 1 VALIDATION
I hereby affirm that 1 am licensed under provisions of Chapter �J, UNJr
9 (commenemg with Section 7000) of Division 3 of the Bust /tel✓f r +Alptj s•
ness and Professions Code and my license is in full force and
effect
License Number Lie Class
CHECK IF SUPERVISED GRADING _ 7 5 R
Contractor Date GNATUR __ _ 1 4i L.
F1
OFA PPLICANT F }) i .' s I. 4
LJ I am exempt from the licensing requirements as I em e �p 1
licensed architect or a registered professional engmeer A RESS i�el vl E � j
acting m my professional capacity (Sect 70el, But ��� f� , �)n 1�.1 �0
mess and Professions Code) SURETY I BOND ( t''
BOND �,J 1.,..i'" NO 4 5NI 7
Lie or Reg No Date SURETY F p G
I COMPANY
HOME OWNER-BUILDER DECLARATION DATE REG D M 4
l FILED BY
I hereby affirm that I am exempt from the Contractors CASH RECD DATE
License Law for the following reason (Section 7031 5 Bust DEPOSIT$ BY FILED ,
ness and Professions Code)
EJI as owner of the property or my employees with THIS IS A LIMITED TIME PERMIT
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) TIME LIMIT i
I 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
I hereby affirm that there is a construction lending agency
for the performance of the work for which th permit u
issued(Sec 309 ry .j. �l�,� �u Q ✓w. . PC Fee$ Permit Fee 11,60
'
Lender's Name F•t/ L.���"
W Issuance Foe /(".,3 (J
Lender s Address ' � S//"'fo/j
I certify that 1 hive rad this application and state that the Total Fee ///J
above information is correct 1 agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authonie reArescritatives of this County to enter
/upop,The above come �o d M perty jgr speftt purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ignat re of Pe ittee .$Date G
C7 Alf/oa . IMCLAJ ��n