HomeMy Public PortalAbout5808 CLOVERLY AVE_Grading__ WORKERS'COM')'ENSATIONDECLARAT[ON 76A641 APPLICATION FOR GRADING PERMIT
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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
a certified copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE
ADDRESS
❑ Certified copy is filed w' h the county building inspection SITE lover Z- Av,� , f ri
ADDRESS LOCALITY
department. LOT
Date Applicant NUMBERS BLOCK NEAREST
TRACT 45817 CROSS STREET
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER DISTRICT NO. MAP NO.]STATE HWY. PROCESSED BY
COMPENSATION INSURANCE }
,., T r� YE ❑ NO � �'
OWNER ) T'2(r#tl atrrfn.rw IRC . C
(This section need not be completed if the work involved qq H
CUBIC v D : U
MAIL Ai =! t';1r :E E" f.. r �.1�. HANDLED:
by the permit is for one hundred dollars ($100) or less.) ADDRESS J
I 1 certify that in the performance of the work for which this CITY X11NO. USE ZONE SPECIAL 11
permit is issued, I shall not employ any person in any manner STATE ,.- CONDITIONS }
so as to become subject to the Workers' Compensation Laws. ENGINEER R`?� "..'_ Shen REG. NO. Ul'JI) ? �
MAIL il!l.) +. F1aIafi �l}-5 �
Date Applicant ( ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate ofCITY �. i`t=3'! )Y'a (ar� TEL' t i ;')- - O
Exemption, you should become subject to the Workers' f NO. 1 d
Compensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL BYUJ
with comply with such provisions or this permit shall be CONTRACTOR NO. DATE
deemed revoked. "
ADDRESS
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I hereby affirm that I am licensed under provisions of Chapter
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 e-
Contractor Date CHECK IF SUPERVISED GRADING ❑
SIGNATURE
❑ I am exempt from the licensing requirements as I am a OF APPLICANT
licensed architect or a registered professional engineer TE ADDRESS NOL • • ` w
acting in my professional capacity (Section 7051, Bug-
iness and Professions Code). SURETY $ BOND
BOND NO.
Lic,or Reg.No. Date SURETY
COMPANY 7
HOME OWNER-BUILDER DECLARATION FILED BYC D
I hereby affirm that I am exempt from the Contractor's, CASH REC'D DATE
License Law for the following reason (Section 7031.5, Busi- DEPOSIT$ BY FILED
ness and Professions Code): THIS IS A LIMITED TIME PERMIT t
OI, 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 the structure is not intended or offered for sale _
(Section 7044, Business and Professions Code). j
❑ TIME LIMIT:
I, as owner of the property, am exclusively contracting + *,
with licensed contractors to construct the project EXTENDED TO: BY:
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency EXTENDED TO: BY:
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). P.C. Fee$ - Permit Fee
Lender's Name
Lender's Address 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 laws 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 Date