HomeMy Public PortalAbout9435, 9437, 9441 BROADWAY_Grading__ WORKF.RS'COMPF.NSA'I'ION DECI.ARA'I'ION 7DAo41T
I hereby affirm that I have a certificate of consent to self insure, CE 807 PEV. 4-80, IO/BO APPLICATION FOR GRADING PERMIT
or a certificate of LWerkeri tompensotion Insurance, or a cer.
tified copy thereof IS 3800, Lab. C.)
_ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Q Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE
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IL
SITE O
❑ Certified copy is filed with the county building inspection ADDRESS LOCALITY 4 U
deportment. LOT
Data Applicant NUMBERS BLOCK CROSS STREET
TRACT LL
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER _ DISTRICT NO MAP NO STATE H PROCESSED BY
COMPENSATION INSURANCE YES ❑ rNO Q R
OWNER CUBIC YDS. - R
(This section need not be completed if the work involved by MAIL HANDLED:
the permit is for one hundred dollars ($100) or less.) ADDRESS - _ R
TEL
I certify that in the performance of the work for which this per CITY NO. USE ZONE SPECIAL W
mit is issued, I shall not employ any person in any manner so as ENGINEER STAREGTENO. , CONDITIONS f
to become subject to the Workers'Compensation Laws. MALL ---
Date Applicant ADDRESS `-
NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITY NO
emption, you should become subject to the Workers'Coni GRADING TEL
cation provisions of the Labor Code, you must forthwith comply CONTRACTOR NO FIN By
with such provisions or this permit shall be deemed revoked. - —.— D E I�
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) �yl� VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license is in full force and effect. YYY
License Number Lic.Class
Contractor Dote a
❑ CHECK IF SUPERVISED GRADING ❑
I am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business ADDRESS TEL e '
and Professions Code). NO.
SURETY E BOND e.
Lic.or Reg.No. Date BOND NO.
HOMEOWNER-BUILDER DECLARATION SURETY a • • +
COMPANY
I hereby affirm Poet I am exempt from the 5, Business License
Low for the following reason(Section 7031.5, Business and Pro- DATE RECD
FILED BY
fesiions Code): CASH RECD DATE –
❑ I, as owner of the property, or my employees with wages DEPOSIT E BY FILED e
as their sole compensation, will do the work and the struc. THIS IS A LIMITED TIME PERMIT - -
ture is not intended or offered for sole (Section 7044,
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Section TIME LIMIT:
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 this permit is issued(Sec. EXTENDED TO: BY:
3097, Civ. C.). P.C. Fee $ - Permit Fee
Lender's Name
Lender's Address 4 Issuance Fee
I certify that I have read this application and state that the Total Fee
above information is correct. I agree to comply with all County
ordinances and State lows relating to building construction,and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dote