HomeMy Public PortalAbout5118 DOREEN AVE_Grading__ WOR KERS'COMPENSATION DECLARATION 76A641T APPLICATION FOR GRADING PERMIT
I hereby affirm that have a certificate of consentinsure, CE 807 REV. 2-80)10/80
or a certificate of Workers' Compensation Insurance,nce, or
ora 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 TE
ADDRESS
❑ Certified co is filed with the count building inspection SITE
PY Y 9 P ADDRESS LOCALITY
department. LOT
a
Date Applicant NEAREST
NUMBERS BLOCK CROSS STREET V
TRACTW
CERTIFICATE OF EXEMPTION FROM WORKERS'
NUMBER DISTRICT NO. MAP NO. STATE HWV. PROCESSED BY
COMPENSATION INSURANCE YES C NO ❑ }
OWNER CUBIC YDS. Q
(This section need not be completed If the work Involved by MAIL HANDLED:
the permit is for one hundred dollen ($100) or lets.) ADDRESS O
TEL d
I certify that in the performance of the work for which this per- CITY NO. USE ZONE SPECIAL
mit is issued, I shall not employ any person in any manner so as STATE CONDITIONS
to become subject to the Workers'Compensation Laws. ENGINEER REG. NO.
MAIL
Dale Applicant ADDRESS
NOTICE TO APPLICANT:If, offer making this Certificate of Ex- TEL
CITY i
emption, you should become subject to the Workers'Compen- NO. '[ G
sotion provisions of the Labor Code, you must forthwith comply GRADING TEL. FINAL BY
P CONTRACTOR NO. DATE �
with such provisions or this permit shall be deemed revoked. A �
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license is in full force and effect.
License Number%^" Lit.Class T
Contractor Date —
CHECK IF SUPERVISED GRADING ❑ �� �!�t
❑ I am exempt from the licensing requirements as I am a SIGNATURE 0 +
licensed architect or a registered professional engineer OF APPLICANT llaa�•AAS�. ..I ITEM
acting in my professional capacity (Section 7051, Business ADDRESS
and Professions Code). TEL.
TV ISR
SURETY$ 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
fessiom Code): FILED BY
❑ CASH RECD DATE 'JINi
I, as owner of the property, or my employees with wages DEPOSIT E BY FILED lseoc. An
��
as their sole compensation, will do the work and the struc- THIS IS A LIMITED TIME PERMIT •IOCIOO An
lure is not intended or offered for sole (Section 7044, .v
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY xQ
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Section TIME LIMIT: MO.
7044, Business and Professions Code). [y�
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: 2 T I�/C rIP
hereby affirm that there is a construction lending agency for CUYA. 1637,
the performance of the work for which this permit is issued(Sec. EXTENDED TO: BY:
3097, Civ. C.). - �i 17'
P.C. Fee b Permit Fee
Lender's Name �A771F
Issuance Fee
Lenders Address I
I certify that I have read this application and state that the Total Fee 1 7/31,
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,and 77% 1 A" CI
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 es