HomeMy Public PortalAbout9445 LAS TUNAS DR_Grading_5/27/1988_ WORKERS'COMPENSATION DECLARATION 76A641T �pp`ICATION FOR G"DING HERMIT
CE 807 (RE V.;2-80) KA
"
I hereby'affirm that I have a certificate. of:.consent to self
insure, 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
. p, q- .C: .9 f
QCertified copy is hereby furnished. FOR APPLICANTJO FILL IN SITE rTj` � ? ;�i yrrr r X44. it
ADDRESS I ' /=••
El
Certified copy is filed with the county building in `ection SITE ESS - *" ✓ "'? '�? �/ • LOCALITY
department. 1, / '
" O
, " -Aplicant NUMBERS BLOCNEAREST
bate r
CROSS STREET
CERTIFICATE OF EXEMPTION FROM WORKERS" TRACTNUMBER 3 DISTRICT NO. N1AP NO.!.STATE HWY., PROCESSED BY
COMPENSATION INSURANCE r / j ?^ ( �' '' YES ❑ NO ❑ CIL
�i +1F ttL. r tt i E `t { '/ - CUBIC YOS -
'(This section need not be completed if the work involved MAILa v Y 1 H qN D L E D
by the"permit.:is' for one'hundred•dollars ($100) or-.less.),,, ADDRESS vnt� ✓"`-' t r' r �u� ✓i1 i ;f r� t , '� LU
I certif ..that in the performance of the work for which this;+ t: ' TELr
y P, CITY f-1 d,� l u' N O.0/9i /� .. .i(� . LL
permit,is.issued, I shall not employ any person in any manner =r f USEFZONE SPECIAL
STATE r {/ CONDITIONS }
so' as-to become subjecf?to the Workers' Compensation Laws. ENGINEER .d�t •r xl:, !REG.pNO.
Date Applicant MA ES f".'y) .AV; �-c ��f t`. �
1 ti cc
'NOTICE TO APPLICANT: If, after makingthis Certificate of f t:': -+ rr ° TEL
CITY r� fl C.•ffs NO.ir�fiL
'Exemption, you' should become subject to •the Workers'
Compensation•provisions of the Labor Code, you must forth- GRADING :TEL. w nv FINAL BY W
with comply with such CONTRACTOR' ' NO 11 _ t`Z DATE
p y provisions or-this permit shall be a—
deemed revoked. ADDRESS ' sal
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I
her affirm that I am'licensed under provisions of Chapter s r Vf F`f! fir ;r•1r21`a'trl;% r v rr�%%
9 (commencing with Section 700,0) of Division 3 of the Busi-
iess•and*Professions Code, and my license is in full force and
ffect Zia
censrNumber ' Lic. Class ? ! i
J y � r al ./. CHECK IF SUPERVISED GRADING
ntrac'tor • Date r' 1
,r .. . SIGNATURE
OF APP.LICANT#4.t '. 4(•''. d-.'' ` € ..F
I am exempt from the.licensing.requirements as I am a
licensed. architect or a registered professional engineer TE L") -) v
acting in my professional capacity (Section 7051, Bus- ?DDRESS. NO. 114� ��
mess and Professions Code). '` SURETY$ BOND
BOND NO.
Reg.No. `Date SURETY
COMPANY
i HOME OWNER-;BUILDER DECLARATION' DATE -REC'D
FILED BY
y affirm that I am exempt from the Contractor's CASH RECD DATE
'Law for the-following reason (Section 7,031.5, Busi- DEPOSIT$ BY FILED
Professions Code): THIS IS A LfMITED TIME PERMIT
aS'•owner 'of.,the ,property, or my employees'with i �,'s E z, �I x
es'-.as-their sole compensation, will do the work i i.F
p. ALL WORK AUTHORIZED MUST�BE COMPLETED BY
the structure is not intended or offered for sale
ction 7044,Business and Professions Code).
TIME LIMIT:
s owner of the ,property, am exclusively contracting
licensed contractors to construct the project EXTENDED-TOi BY:
tion 7044, Business and Professions C(!de).
i^
CONSTRUCTION LENDING AGENCY' ? ft c�x
by affirm that there is a construction lending agency,
_
EXTENDED TO BY:
e', performance of the work for*which this permit is j�_ i lf. v�+a+
( ec. 3097,Civ:C:). P.C.,Fee$ Permit Fee f c t
s.Name . a j / i
Issuance Fee fir`
r s Address ry
ify that C have read this application, and state that the' Total Fee [ j r_.r •-� +` '"
information is correct. I agree to comply with•alLCounty ' r
n;ces and State laws relating to building construction,
ieby authorize representatives of this County to enter
he above-mentioned propert,y^for,inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE "
A:
_
ture of Permittee-'' Date