HomeMy Public PortalAbout5430 ENCINITA AVE_Grading__ WORKERS' NSA'I'ION DFCLARA'1l(3N 76A641T p pp y g� p1"• 1 /may®'-I��`p ng p
I hereby affirm that I Awcertificate of consent to self insu,e CE 807 TIREV..2,80) 10/80 _ — A f L�1 ION Foix. 47fi AD1'Pd\Y`P6E,RM'1-._. .
or a certificate of Worf.ers'Compensation Insurance, or a cer- �;I
tfmd copy thereof(Sec. 3800, Lab. C.) - _ : - -" COUNTY OF LOS ANGELES ,jjiy BUILDING AND SAFETY,
- ". Na. Company Fl°a_I T�15L7(IAtJCJ �J. _ ,L V
A. ? SITE /�j�
Certified copy is hereby_tu!nisFied s w FOR APPLICANT TO FILL IN .ADDRESS + ap-f a
?;. •t, F. y •e _ � SITE o
❑'Certified copy is filed with the county building Q pection ADDRESS " Lif/1/ LOCALITY
' department ,s 1s IOT ' NEAREST 2'
Dote—APPI Cool SL'1MJrT �rl^wT Crl�\� _ NUMBERS TRACTc�� BLS CROSS STREET % Q.
< NUMBER �7 j1�"• ._s.. _ Y mSTRICi Np � pROCE
It, CERTIFICATE OE EXEMPTION FROM WORKERS r J/ YES O NO IY
! COMPENSATION INSURANCE..+ ,; OWNER p/ . cd "" - 1t.
.y LJn° ' .CUBIC YDS. - fD
MAIL 11 :HANDIED:' /
1'hb section need not bo comploted if tho work itrvolved by ADDRESS O �17�t1��. /" C �r + 8
%io permit Is for one hundrod dollars(9100)or lesa_)y - �-
s . TEL. C n
I certify that in the performance of the work for which this per- 1, CITY •� r,tej NO. Q�Q USF NE-, SPECIAL- -
md is issued, I sholl not employ any person in eny,monner-so ost // � 5e,4,7 REG.NOSTATE ,•= ONDITIONS - d
,( . W tS
Io became subject to the Workers"Compensation Laws. - ENGINEER /j �.s MAILI •/u, .- ---• - - '- t
?ale' + Applicant + � - ADDRESS h �O�
NOTICE TO APPLICANT:if after moking,fhis Certificate'of Es- J CITY NO
emption, you should become subject to the Worker.Compe.. GRADING TSI.
sation provisions of the Labor Code, you must forthwith comply DATE
FINAL
r.
CONTRACTOR NO. - BV -
With such provisions othis Permit shall be deemed revoked. DATE
•. ` ADDRESS
LICENSED CONTRACTORS DECLARA'I ION, 1 i
hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) _.___ _._. _.__.."._: VALIDA710F
(commencing with Section 7000) of Division 3 of the Business ; - )
and Professions Code,and my license is in full force qD�j�(feSr. — --" - "-'�"' - -
f 1(/ W iqo #
License Num r d Lk.Class
� � s, l .aril T 1 . 33000 r f3
[antractor ata - -
i CHECK IF SUPERVISED GR NG - -e-3 3 (1 O Q T Cs t
Elam exempt from the licensing regbiraments as I am a SIGNATURE t
licensed architect or a registered professional engineer OF APPLICANT
A.: acting in my professional capacity (Section 7051, Business -f s Oc fiQ ��d� ` - --- -- -- `�: ; ,tY
and Professions Code). , 1 - ADDRESS - ! [ `
SURETY$ BOND
Lic.or Reg.Na. Date BONDNO. r
•"' HOME OWNER-BUILDER DECLARATION SURETY
COMPANY:
I hereby affirm that I am exempt from the Contractor's License DATE _ RECD
Law for the following reason(Section 7031.5;Business and Pro- k FILED - BY
Sessions Code): CASH RECD DATE'- I - a A y h V AMTS
❑ I, as owner of the property, or my employees with wages DEPOSIT 9 -- ' BY "' • ' FILED -' �TsrELs�l s9 ��fs �s
to their sole compensation, will do th sale and the strut THIS IS A LIMITED TIME PERMIT-- -
lura is not intended or offered for sole (Section 7040, " 1
_ Business and Professions Code). - s:f - t •tUA , r
ALL WORK AUTHORIZED MUST BE COMPLETED By IW
❑ I, as owner of the property, am exclusively contacting tyil�. -340.' 50
with licensed contractors to construct the project (Section t TIME LIMIT:
_._. if
704, Business and Professions Code).
CONSTRUCTION LENDING ACF.NCY EXTENDED TO: BY:
-- 00
1 hereby affirm that there is a construction lending agency for .EXTENDED TO- BY:
the performance of the work for which this permit is issued(Sec. 4
3097. Civ. C.). { P.C. Fee $ �' .Q , Permif Fee
Lender's Name d: - s _ Issuance Fee.!S�'. '}Lt .�`6-: "�• ((L� E r AAssss -
• 4 I � _ S1 s T76:�. •�� ...NI $igl.
Lender's Address - a I
I aer0y 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 _ _ r' _ _. _ „• _ . _ _ _ .. _. _ t
,he va-me coned operty far inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
al