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HomeMy Public PortalAbout9021 EMPEROR AVE_Grading__ WORKERS'COMPENSATION DECLARATION T APPLICATION FOR GRADING PERMIT CE 807 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 E] Certified cois filed with the county building inspection SITE �G^�37, Certified ADDRESS .: LOCALIT department. LOT /'_� Date Applicant NUMBERS [C(`.J— G BLOCK NEAREST CROSSTREET CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT 71,yJa D IC M P NO. STATE HWY. PROCESSED BY COMPENSATION INSURANCE NUMBER Ya YES ❑ NO OWNER ty CUBIC YDS. } (This section need not be completed if the work involved MAILHANDLED: 0 by the permit is for one hundred dollars ($100) or less.) ADDR ;E SSS � "�� 5 � TE I certify that in the performance of the work for which this CITY �_JCL_3 EM NOL 41Z. �IA IX permit is issued, I shall not employ any person in any manner US ON SPECIAL -7 " � STATE CONDITIONS ��� /v'� j �� so as to become subject to the Workers' Compensation Laws. ENGINEER�Lri N REG. NO. U MAIL ' 4� WW Date Applicant ES 1 gg0. NOTICE TO APPLICANT: If, after making this Certificate of NOL yr to CITY Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL BY with comply with such provisions or this permit shall be CONTRACTOR NO. DATE deemed revoked. ADDRESS LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. License Number Lic.Class Contractor Date CHECK IF SUPERVISED WADING SIGNATURE ❑ OF APPLICANT / I am exempt from the licensing requirements as I am a 57 licensed architect or a registered professional engineer O) a✓L{�3�'=,+ TEL. ADDRESS r ff-N O. q2 acting in my professional capacity (Section 7051, Bus- iness and Professions Code). SURETY$ BOND / BOND NO. Lic.or Reg.No. Date SURETY CO_,MRANY % HOME OWNER-BUILDER DECLARATION FDATE BRYC'D 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 ❑ 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 and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). 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 1 EXTENDED TO: BY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). P.C. Fee$ (1 Permit Fee Lender's Name Issuance Fee Lender's Address 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 / y ordinances and State laws relating to building construction, / and hereby authorize representatives of this County to enteri upon the above-mentioned property for inspection purposes. -"#L—S E I{EVERSTFOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 807 807 T r APPLICATION FOR GRADING PERMIT I hereby affirm that I have a certificate of consent to self insure, CE (REV.•2-80) 10/80 or a certificate of Workers' Compensation Insurance, or a ce'r- . &. �"� tified copy thereof (Sec. 3800, Lab4iiltoW12Z�4�0 COUNTY OFLOS ANGELES BUILDING AND SAFETY PolicyNo�Company ',41 F-1Certified co is hereby' R APPLICANT TO FSITE PY furnished. FOR ILL IN ADDRESS �� -2- � i�1---��j LfT�A SITE F] r Certified copy is filed with the county building inspection ADDRESS �m � �J k LOCALITY' '�' department. LOT � C-1 Date "�I Applicants NUMBERS 40-st? BLOCK CROSSSSTREET �DMfc-.�°+� TRACT a.. CERTIFICATE OF EXEMPTION FRONT WORKERS' NUMBER _ DIS! NO MAP NO. STATE H N PROCESSED BY COMPENSATION INSURANCE OWNER ,�y�Q 2 gfr fJ als' 11 CUBIC 7 YES ❑ NO 67G (This section need not be completed if the work involved by MAILHANDLED: the permit is for one hundred dollars($100)or less.) ADDRESS �f 7 S7. I certify that in the performance of the work for which this per CITY /✓© +j NO. 7-1 —4 0 USE ZONE SPECIAL mit is issued, I shall not employ any person in any manner so asIL STATE _ CONDITIONS 1�4 i d .to become subject to the Workers'Compensation Laws. MA LNEER�lCj�S S 1-11 I�! REG. NO. � Date Applicant ADDRESS -1 TcyN/ L NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITY `�rt NO. .-® O emption, you should become subject to the Workers'Compen- uVi GRADING TEL. FINAL BY sation provisions of the Labor Code, you must forthwith comply r b}y G]. p p ( CONTRACTOf q'� 7 O. L c� T'�Z� DATE with such provisions or this permit shall be"deemed revoked. LICENSED CONTRACTORS DECLARATION ADDRESS,$( OVY, fL !2177,6 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 j /+a and Professions Code,and my license is in full force and effect. / J�JT C 66!!� 7 C -04eAft censeNumber3Z Lic.Class-� 4 5,9,9 A ��po ntrac to7ti ,.✓Ta to !��'�"^� 0 0 0 0 1 8 CHECK IF SUPERVISED GRADING Z�° 39500 F-1I am exempt from the licensing requirements as I am a SIGNATURE licensed architect or a registered professional engineer OF APPLICANT �o c acting in my professional capacity (Section 7051, Business TEL [�q 17 9 5 0 01-7-3 and Professions Code). ADDRES57Rj1-SrR}KA6EJiA g NO `� r 6 S� SURETY$ n Oc BOND 0 -. 1 8-83 Lic.or Reg. No. Date BOND fJ r NO. .3$A, Sc HOME OWNER-BUILDER DECLARATION SURETY I hereby affirm that I am exempt from the Contractor's License COMPANY G1rC�V /. Op Gs Law for the following reason (Section 7031.5, Business and Pro- DATE RECD 5.5 3 1.9 A fessions Code): FILED BY CASH REC'D DATE f n o 0 0-0 4 ❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED as their sole compensation, will do the work and the strut- THIS IS A LIMITED TIME PERMIT 2'- 4 05.50 ture is not intended or offered for sale (Section 7044, Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY j0 ° 4 0 5'5 0 ❑ I, as owner of the property, am exclusively contracting i with licensed contractors to.construct the project (Section TIME LIMIT: � ,_ ,�:� 09. 1 '6-.8,3 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. EXTENDED TO: BY: 3097, Civ. C.). P.C. Fee$ Permit Fee Lender's Name Issuance Fee �¢J„ S-C, Lender's Address _ I certify that I have read this application and state that the Total Fee 01- 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 oentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r$i6l"6tur4 of Permittee Date Os