HomeMy Public PortalAbout6210 CAMELLIA AVE_Grading__ WORKERS'I COMPENSA'T'ION of consent t se 76A641 APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80) 10180
or a certificate of Workers'Compensation Insurance, or a cer-
tified copy thereof(Sec. 3800, Lab C.�.
r r r � � ,•, 4_., ._- �. �,��� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 't '�' �ompanySITE
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❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS O
( SITE
LTJ Certified copy is filed with the county building inspection ADDRESS LOCALITY �' U
depar ment r, - / LOT W
' { e`s tlf � NUMBERS BLOCK NEAREST s j LL
Date pplicant ...1 f 1 s TRACT CROSS STREET
NUMBER DISTRICT NO. MAP NO. STATE HWY. PROCESSED BY }
CERTIFICATE OF EXEMPTION FROMWORKF,RS' -"
COMPENSATION INSURANCE. - YES❑ NO W
OWNER CUBIC YDS. cc
(This section need not be completed if the work involved by MAIL HANDLED
the permit is for one hundred dollars ($100)or less.) ADDRESS
TEL.
1 certify that in the performance of the work for which this per- CITY NO. USE,ZONE y SPECIAL LU
mit is issued, I shall not employ any person in any manner so as STATE — CONDITIONS
to become subject to the Workers'Compensation Lows. ENGINEER REG. NO. �J
MAIL
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- CITY ` NO. �02� ��
emption, you should become subject to the Workers'Compen-
sationprovisions of the Labor Code, you must forthwith comply CONTRACTOR " NO. ATE
with such provisions or this permit shall be deemed revoked.
ADDRESS PROPOSED LICENSED CONTRACTORS DF.CLARA"PIONI hereby affirm that I am licensed under provisions of Chapter 9 SED USE OF GRADED SITESVALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
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License Number � '-tic.Class
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Contractor- ; o =t �q ,,e i ,� •
4 CHECK IF SUPERVISED GRADING
❑ 1 am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business TEL
and Professions Code). ADDRESS NO.
SURETY$ BOND
Lic.or Reg.No. � E-� Date - r r'` �` BOND NO.
HOME OWNER-BUILDER DECLARATION SURETY y'
COMPANY
I hereby affirm that I am exempt from the Contractor's License DATE REC'D
Law for the following reason (Section 7031.5, Business and Pro- FILED BY
fessions Code): A
CASH RECD DATE dA
❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED :V
as their sole compensation, will do the work and the struc-
ture is not intended or offered for sale (Section 7044, THIS IS A LIMITED TIME PERMIT 303 '.4
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY '23
❑ 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: r=
I hereby affirm that there is a construction lending agency for EXTENDED TO: BY: 4
the performance of the work for which this permit is issued(Sec. ct.0
3097, Civ. C.).
P.C. Fee$ Permit Fee w
Lender's Name 1; 1 45.6
Issuance Fee
Lender's Address
I certify that I have read this application and state that the Total Fee MAL
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,and •. t' r
hereby authorize representatives of this County to enter upon
the ab/ove/mention d propertfor nspection purposes. , SEE REVERSE FOR EXPLANATORY LANGUAGE ..t�-
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Signature of Permit Date T