HomeMy Public PortalAbout9450 BROADWAY_Grading__ WORKERS'COMPENSATION DECLARATION CE 807 T Q����6�0 ®� rn®rte GU
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CE 807 (REV. 2-80) a u FOR
IWW/W1 W IWWIWYIII III JI'
1 hereby affirm that 1 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
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDREss !✓%ZG/+Z��L°
❑ Certified copy is filed with the county building inspection SITEAD R S �� �i2QAfJC.Uf1L- LOCA LITV !- -
department. -
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Date Applicant NUMBERS BLOCK NEAREST //----
CRO SSTREET ,�v vim'
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT DISTRICT NO, MAP N STATE HWV, PROCESSE V
COMPENSATION INSURANCE NUMBER ,yr n/,^� Y�� �-� U A�
OWNER ?+InF C/ D GOS//]/ 11 AIG Y ❑ NO -
(This section need not be.comple[ed if the work involved CUBIC YDS. r i•O
MAIL /� FF p,r1,. HANDLED: q
by the permit is for one hundred dollars (S100) or less.) DDRE S -/40 �� C• U/�t1 ,�7G✓ . l LSP:.��/ a
1 certify that in the performance oft a work for which this CITY Pte- G NO. 6k 17 y /,
permit is issued, I shall not em y y person ' any manner e� nom. r��7[,q USE ZONE SPECIAL
so as to become subject to th W r s' Confpens tion Lay ENGINEER J• �' ��/WN REGTNOC / D O CONDITIONS cr
Date Applicant "AP'IL ^J Q E . DICT—/'—A R/J//{_'f�'U'C• O
NOTICE TO APPLICANT: If, after maki g this Certificate of �. p TEL. ! U W
Exemption, you should become subject to the Workers' CITU `iL^/v/'�' r NO. !C/��Ob J 7
Compensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL ^e BY Z
with comply with such provisions or'this permit shall be CONTRACTOR NO. DATE off/
deemed revoked. ADDRESS
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I hereby affirm that 1 am licensed under provisions of Chapter �S(i��67VGC ♦A
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
I
Contractor Date CHECK IF SUPERV ED DING �/ O�
SIGNATURE / OY 01D
❑ L
I am exempt from the licensing requirements as I am a OF APPLICANT TEL
licensed architect or a registered professional engineer ADDRESS ,L.g/y[) f/ NO. jIO'J�I� Q•
acting in my professional capacity (Section 7051, Bus- �r73
iness and Professions Code). SURETY$ BONE)
BOND N
Lic.or Reg.No. Date SURETY
COMPANY
HOMEOWNER-BUILDER DECLARATION DATE REC'D
FILED BY
I hereby affirm that 1 am exempt from the Contractor's CASH RECD DATE
License Law for the following reason (Section 7031.5. Busi- DEPOSIT$ BY FILED
ness and Professions Code): THIS IS A LIMITED TIME PERMIT
❑ 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 he structure is not intended or offered for sale
on 7044, Business and Professions Code). TIME LIMIT: 'p
1, as owner of the property, am exclusively contracting <2 5.3.•5 A
with licensed contractors to construct the project EXTENDED TO: BY: # e e e e o ((
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: d I0 2 b O.G O
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is '
issued (Sec. 3097.Civ.C.). P.C. Fee$ �J Permit Fee ^ 0 2 6 0.5 0 6
Lender's Name r
t
Lender's Address Issuance Fee O / 0!6 0 6-8 3
1 certify that 1 have read this application and state that the Total Fee
above inf motion is correct I agree to comply with all County !�
ordinance and Sil�za
e law relating to building construction, - 7
nnauthoe repress [a[ives f, this County to enter
U n the - r r 4spection purpo es. ��. SEE REVERS17 17OR EXPLANATORY LANGUAGE
Signatu e o Date '