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HomeMy Public PortalAbout5806 & 5808 CLOVERLY AVE_Grading__ WORKERS'COMPENSATION DECLARATION 76A641 APPLICATION FOR GRADING PERMIT I hereby affirm that I have a certificate of consent to self CE 807 (REV 2 80) insure, or a certificate of Workers'Compensation Insurance,or 'fl a certified copy thereof(Sec 3800,Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY > Policy No Company `y Certified copy is hereby furnished FOR APPLICANT TO FILL IN SITE/ ADDRESS J�OC3 V Certified copy is filed with the county building inspection SITE 808 C 1 o v e r 1 y Ave . TempleCi t.� CALITY department ADDRESS L LOT NEAREST Date Applicant NUMBERS BLOCK TRACT 45817 CRO STREET CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER DIST ICT O MAP NO STATE HWY P ESSED BYi COMPENSATION INSURANCE ,© 87�'z(o Y ❑ O OWNER F D C Industries Inc CUBIC YDS >_(This section need not be completed if the work involved MAIL 1 216 Garfield Ave . 2 01 HANDLED a by the permit is for one hundred dollars ($100) or less) ADDRESS �j"]'j 0 I certify that in the performance of the work for which this CITY Alhambra CA NOL(81 8) 2 8 0 0 4 4 permit is issued, I shall not employ any person in any manner aqo US ZONE SPECIAL O y_ CONDITIONS TAT i � so as to become subject to the Wor rs' Comprnsation Laws ENGINEER Engles Shen REG NO 18 06 ° _�V_ _ —' - MAIL- Dat l (�LiCXii�i' - -600 W� Main St . #� 205Y - - w — a ADDRESS NOTICE TO APPLICANT If, after makingthis Cer icate of TEL CITY Alhambra CA No 818 282-68 1 Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth GRADING TEL FINAL BY with comply-with such provisions or this permit shall be CONTRACTOR NO DATE deemed revoked t ADDRESS LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITES) y VALIDATION [ hereby affirm that I am licensed under provisions of Chapter � L� l�l✓'GO NITS 6,000 (commencing with Section 7000) of Division 3 of the Busi , 9 2 A " less and Professions Code, and my license is in full force and affect ` # 0 0 0 0) 8 ,icense Number Lie Class 1 - 59250 :ontractor Date CHECK IF SUPERK ED G I SIGNATURE 71 I am exempt from the licensing requirements as I am a OF APPLICA ��QQ pp [ _ licensed architect or a registered professional engineer ADDRESS �� M NOL(, 28Z�68�) ° ° 5 9 2 5 0 5 acting in my professional capacity (Section 7051, Bus iness and Professions Code) _ ` SURETY$ _ BOND0308-88 BOND - NO, Lie or Reg No Date "SURETY COMPANY r� HOME OWNER BUILDER DECLARATION FDI LED i'i C D Qq QR j 8'&,-00q'7 &,-00q / I hereby affirm that I am exempt from the Contractor's I>t'•istf' {�/SQ EC D 1C1 DATE 6 ✓ Ofi(J/fit/�� License Law for the following reason (Section 7031 5, Busi $ J /V BY �. FILED 3 ness and Professions Code) THIS IS A LIMITED TO& PERMIT 2977.1 A I, 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 # s e o • 0 3 and the structure is not intended or offered for sale (Section 7044, Business and Professions Code) TIME LIMIT J - 603.00 I, as owner of the property, am exclusively contracting °J° 6 0 3 0 0 c=i with licensed contractors to construct the project EXTENDED TO BY (Section 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY EXTENDED TO BY 0603-88 1 hereby affirm that there is a construction lending agency T for the performance of the work for which this permit is v issued (Sec 3097,Civ C ) PC Fee$ 2 J V Permit Fee Lender's Name ' Lender s Address Issuance Fee S—J7 = ♦� I certify that I have read this application and state that theb j Total`Fee 0 k above information is correct I agree to comply with all County ; ordinances and State laws relating to building construction, and hereby authorve representatives of this County to enter upon the ab `ve mentioned property for inspectio purposes SEE REVERSE FOR EXPLANATORY LANGUAGE i Signa e' Kieitlee Date Liu f