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WORKERS'COMPENSAT[ONDECLARATION CE
APPLICATION FOR GRADING PERMIT
CE 807 (REV. 2-80)
I hereby affirm that I have a certificate of consent to self
inf+re,or a certificate of Workers'Compensation Insurance,or
iarltified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Aolfcy No. - ' Company t
F1CertCertifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN SIgDTOEREs$ /7 rin - �✓C'
p'❑
E
Certified copy is filed with the county b ilding inspection SITS+ E - LOCALITY rf
deparimeI I I _ LOT
Date ' Applicant NUMBERS BLOCK NEAREST
CERTIFICATE OF EXEMPTION FROM WORKECTO. M O
RS' TRACT
NUMBER f' DITAINPN . TATE HWY. ESSED BY
COMPENSATION INSURANCE ( p/ Y O 0
CUBIC(This section need not be completed if the work involved OWNER '� HANDLED 1�
by the permit is for one hundred'dollars ($100) or less.) MAIL ADDRESS L
I1 certify that in the performance of the work for which this CITY NOL ✓/ LL
permit is issued, I shall not employ any person in any manner USE ZONE SPECIAL
STATE CONDITIONS }
5o as to become subject to the Workers' Compensation Laws. ENGINEER REG. NO. It
Date Applicant MAIL ADDRE
SS cc
NOTICE TO APPLICANT: If, after making this Certificate ofCITYf NOL ' a
Exemption, you should become subject to the Workers' 0,
Compensation provisions of the Labor Code, you must forth- GRADINGTEL. FINAL BY W
with comply with Such provisions or this permit shall be CONTRACTOR NO. DATE
deemed revoked. ADDRESS
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000)-of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number Lic. Class '
Contractor Date f - (/ CHECK IF SUPERVISED GRADING.❑ L
SIGNATURE {
❑ OF APPLICANT r :�
I am exempt from the licensing requirements as I am a
licensed architect' or a registered professional engineerqDD ADDRESS NO.
1 .
acting in my professional capacity (Section 7051, Bus-
inessandProfessionsCode . SURETY $ BONDa
{
BOND NO.
Lic.or Reg.No. Date SURETY
COMPANY
HOMEOWNER-BUILDER DECLARATION FDATE BVC'D (_ i
1�
I heraffirm that am exempt from the Contractor's CASH RECD DATE
Licensese Law for the following
lowing reason (Section 7031.5, Busi- DEPOSIT$ BY FILED ♦ • (.N �(�G�
ness and Professions Code): THIS IS A LIMITED TIME PERMIT �h
❑ 1, as owner of the property, or my employees with
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, as owner of the property, am exclusively contracting
with licensed contractors to construct the project EXTENDED TO: BY:
(Section 7044, Business and Professions Lode).
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY:
I hereby affirm that there is a construction lending agency
for the performance,of the work for which this permit is j /1
issued(Sec. 3097,CA )., P.C. Fee$ �/ G:+ Permit Fee
Lender's Name
Lender's Address issuance Fee /0 � V
I certify that I have read this application and state that the Total Fee J. , a
above information is correct.I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon tha,above-mentioned'property for inspection purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE
4
Signature of Permittee Date -