HomeMy Public PortalAbout9451 BROADWAY_Grading__ WOR KERS' have a NSAIION DECnsentt se CE76A64 I 807T APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80) 10 80
or a certificate of Workers' Compensation Insurance, or a cer-
tified copy thereof(Sec. 3800. Lab, C� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No -'- /Company ° F
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SIIDDRESS 6
�y SITE U
L 'J Certified copy is filed with the county building inspection ADDRESS - - LOCALITY
depyriment. LOT NEAREST W
Dote / ' Applicant �` '-�� NUMBERS BLOCK CROSS STREETTRACT
LL
NUMBER DISTRICT NO MAP NO. STATE HWY. PROCESSED BY >,
CER"LIFICCO E SATION ON FROM WORKERS' YES❑ NO ❑
COMPENSATION INSURANCE - -
OWNER - CUBIC YDS.
6
(This section need not 6e completed if the work involved by MAIL HANDLED: p
the permit It for one hundred dollars ($100) or less.) ADDRESS
TEL f
1 certify that in the performance of the work for which this per- CITY NOUSE ZONE SPECIAL H
mil is issued, I shall not employ any person to any manner so as STATE CONDITIONS
to become subject to the Workers"Compensation Laws. ENGINEER REG. NO.
MAIL
Dote Applicant ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- TEL
emption, you should become subject to the Workers'Compen- CITY NO.
solion provisions of the Labor Code, you must forthwith comply GRADING TEL FINAL BY
with such provisions or this permit shall be deemed revoked. CONTRACTOR NO. DATE
LICENSED CONTRACT-ORS DECLARAIION ADDRESS -
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license is fr full force and effect.
License Number -1' bc.Class CLQ
Contractor Date ❑
❑ CHECK IF SUPERVISED GRADING
I am exempt from the licensing requnements as I am a SIGNATURE
licensed architect or o registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business ADDRESS TEL
and Professions Code). NO.
SURETY E BOND
Lic.or Reg. No. Date BOND NO.
HOMEOWNER-BUILDER DECLARATION SURETY
I hereby affirm that I am exempt from the Contractor's License COMPANY ,
Law for the following reason(Section 7031.5, Business and Pro- DATE RECD -
fessions Code): FILED BY
CASH REG"D DATE
❑ I, as owner of the property, or my employees with wages DEPOSIT E By FILED
as their sole compensation, will do the work and the struc- THIS IS A LIMITED TIME PERMIT
lure is not intended or offered for sale (Section 7044, ..
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY
❑ 1, as owner of the property, am exclusively contracting TIME LIMIT:
with licensed contractors to construct the project (Section .
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: -
I hereby affirm that there is o construction lending agency for
the performance of she work for which this permit is issued(Sec. EXTENDED TO: BY:
3097, Civ. C.). P.C. Fee E Permit Fee
Lender's Name
Issuance Fee
lender's Address -
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 laws relating to building construction,and
hereby puTFsari a rgqppresentatives of this County to enter upon
the aboi`=rte tionbd property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signtfiltbor4dIt Permittee Dole 1
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