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HomeMy Public PortalAbout4504TEMPLE CITY BLVD_Grading (2) rs 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 -