HomeMy Public PortalAbout4503 ELLIS LN_Grading__ WORKERS'COMPENSATION DECLARATION CE 807 ( /�(�P(� CAMOM FOR �Imuds ��WUV n "
CE 807 (REV.2-80) ° l! LS o IftJ - �--
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or Ifl I
a certified copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No�4s1 Compan y�+)�- ', KZ-t'f%A
❑ Certified cop's hereby furnished. p RESS
� ' 'FOR APPLICANT TO FILL IN SITE '' `f"
/�: �Ol ADD
5;rCertified copy is filed with the county building inspection SITE
department. DRESS — l F% v(J. f CALITY
Date Applicant LOT NEARESTNUMBERS BLOCK CROSS STREE ✓r✓�
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT . P O STATE HWY. 6
NUMBER
COMPENSATION INSURANCE IJU��
� � O YQ ❑ NO
(This section need not be completed if the work.involved OWNER :1. G'
CUBIC v D:
P MAIL �x HANDLED: ff t1
by .the.permit is for one hundred dollars ($100) or less.) ADDRESS �If '4JLJO �� '' -� �: 0
G e , SkA
I certify that in the performance of the work for which this \ f `fr TEL.
CITY �'I�k rr,,J NO. y13 $� ��' Z• USE ZON SPECIAL
permit is issued, I shall not employ any person in any manner STATE CONDITIONS 0
so as to become subject to the Workers' Compensation Laws. ENGINEER. 160A�� REG. NO. I—
MAIL
Date Applicant DDRESS "ll3'� 7'. � �• moi£ a,
Cn
NOTICE TO APPLICANT: If, after making this Certificate of S „� TEL. .. z
Exemption, you should become subject to the Workers' CITY tT: NO.
Compensation provisions of the Labor Code, you must forth- GRADING j.O'isj !�f?GY L. ��l 1,`� FINAL BY.
p p y CONTRACTOR DATE
with comply with such provisions or this permit shall be
dee"med.revoked.
ADDRESS 'P•t) vZQ� hr'7. 19QGL'b
'LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness,and Professions Code, and my license is in full force and
effect.
License Number Lic.Class
al CHECK IF SUPERVISE I G
Zonttactor t.+�. i-�'f :rr•= Date h I'i lJ
SIGNATURE
❑ OF APPLICANT- 1 x
I am exempt'from the licensing requirements as I.am a
licensed architect or a registered professional engineer �, E Li
ADDRESS Il �1.rt•I{�. 1 NO
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). SURETY$ BOND
BOND NO
Lic,or Reg.No. Date SURETY
'COMPANY
HOMEOWNER-BUILDER DECLARATION DATE RECD
FILED BY
I hereby affirm that I am exempt from the Contractor's CASH RECD DATE
License Law for the following reason (Section 7031.5, Busi- DEPOSIT$ BY FILED
ness and Professions Code): THIS IS A LIMITED TIME PERMIT
ElI, 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). ?3 4 A 4.A
F-1
1, as owner of theproperty, am exclusively contracting TIME LIMIT:
with licensed contractors to construct the project 11 #,0 0'0 0 o [,I
(Section 7044, Business and Professions Code). EXTENDED TO: BY: -
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: ,2 - 1 87.00
I hereby affirm that there is a construction lending agency _
for the performance of the work for which'this permit is • 0 0 18 7 0 0
� U
issued(Sec. 3097,Civ.C.). P.C. Fee$ Permit Feej O�
Lender's Name
,117-80
Lender's Address - Issuance Fee 7�
I certify that I have read this application and state that the Total Fee
above information is c rrect. I agree to comply with all County
ordinances a d tate laws
relating to building construction, ,//
and hereby z epresentatives of this County to enter
e
upon the a roperty for i spipn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature 0111PbrVitte Dat