HomeMy Public PortalAbout5434 ENCINITA AVE_Grading__ 376AiS11T F
WORKERS' NSA'LION DECI.ARA'I'ION i, �' ` s ti\
_CE 8071REV..Z80) 10,80 APP TIOR1 F044 GSA®II G._PE RAID
I hereby affirm shotcertificote of consent to self insure, -or a certificate of War d Compensation Insurance, or a cer-
t f ed copy thereof(Sec. 3800, Lob. C.) . COUNTY OF LOS ANGELES BUILDING AND SAFETY. \ 7 i
FAzRMaA r 15ORMJCO CID \
Policy No: Company. .i `
u .. .. SITE X
Certifiedtopy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
SITE
Certified copy s filed with the county building inspection ADDRESS �Z Gx/Iy - LOCALITY , �
�. v,
department. ,.. 1,*� 1c `} y. LOT - _ - BLOCK - NEAREST "} R
E ,y1117-� SIW J'1gWl C�'ITII� NUMBERS �� ..
Date Applicant - TRACT CROSS STREET
F` s,.. .. _ l 4 _
DISTR
r CERTIFICATE OF EXEMPTION FROM.WORKERS'.' f{j NUMBER (� �-7ryt p,
COMPENSATION INSURANCE, ��'' J/ /Jr/ VES❑ n10 yE
OWNER Q SAA, [,,J.,' .CUBIC YDS. LL'
Y
MAIL HANDLED: f0
i(This section need not ba completed if the work involved by ADDRESS O �C/u G .�r' ' �S`.� - - 2
fit*permit is for one hundred dollars($100)or less.) j t TEL. CG _-
I certify that in the performance of the work for wh¢h this per- I CIN /r Qi NO. Qy8 - IUSEgNE SPECIAL
mit is issued, I shall not employ any person in any*ma nne,,so as ENGINEER G ` STATE /[- ONDITIONS
to become subject to the Workers'Compensation Laws. '�^-s ��Ch REG. NO.
MAILitsZJ •1
Pits_Applicant _ ADDRESS 7 .»- TEL _.�.. ._. .. _. L
NOTICE TO APPLICANT:If, after making this Cerhficote of Ex- ,¢ CIN rrLj' NO I� u.�Ga�^OS�� j + -
is on, you should become subject to the Workers'Compen- GRADING TEL. ; }
lotion provisions of the Labor Code, you must forthwith comply CONTRACTOR NO. FINAL BY--
with such provisions or this permit shall be deemed revoked. DATE O y qo ff
• ADDRESS - S
..,4•' LICENSED CONTRACTORS DECLARATION.
I hereby affirm that I am licensed under provisions of Chapter 9 � PROPOSED USE OF GRADED SITE(S) ..-_ . ._, VAUDATIO
(commencing with Section 7000) of Division 3 of the Business - f
and Professions Code,and my license is in full force q�d fe L - '- - •) - 9({(
# v e e e
Lice Numtaer 53�d�� L .Class ^/ � .... ,,,_. - _ . .
Contr�actor JJTT Its y S �._ 1033000
S
CHECK IF SUPERVISED GR NG� - _ c _w 4`y. F .,tpl .ate 3 3 0'0
c.0� T
❑'I am exempt from the licensing requirements as I am a SIGNATURE .t .e,. - �- ----- i , \\: 4- -
• licensed architect or o registered professional engineer OF APPLICANT i \ v C!p
_•� acting in my professional capacity(Section 7051;Business 'ADDRESS `I 4Y' TEL { �,,, i} \ 1 ?' w S"$ y-r
T
and Professions Code) S �O' ' v a 4
1 SURETY$ BOND `may 1<1
Lia.or Reg.No. Date BOND _ NO: t - - - - 1- 'i t
3 x
r"- HOMEOWNER-BUILDER DECLARATION t SURETY,. - ! - y A akr P .._i +,•
COMPANY
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason(Section 7031.5, Business and Pro- FAD BY RECD - - -
�essions Code): ; -
CASH RECD DATE_ 1 1 rMAr l v 9
j❑ I, as owner of the property, or my employees with wages DEPOSITS BY FILED" ' - ��Tvs� --- �7-�E�-�s
as their sole compensation, will do the work and the struc- '? THIS IS A LIMITED TIME PERMIT. i ;I - .7vlvt --" `0.501
tura is not intended or offered far sale (Section 7044, r - e� ITEM
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMRETED BV { -
❑ I, as owner of the property, am exclusively contracting ,j i r - INAL . 340.50
TIME LIMIT:
_ with licensed contractors to construct the,prolect (Section
7044, Business and Professions Code). /vLs�Lky� J'sV av1V'
EXTENDED TO: BY: bFTr7RvsiL�
CONSTRUCTION LENDING AGENCY " { I OD
-
6 hereby affirm that there is a construction lending agency far I� c-
the performance of the work for which this permit is issued(Sec EXTENDED TO: BY
3097. Civ. C.). P.C. Fee$ 3 Q . Permit Fee •Q` I _4 ♦ _ \�4 �� wax�wWl\;4 '7/14�
"Linder s Name $ 11 Ay
t .,IssuanceF_eri is "N%\ isv !! t,; sq' SL
Lender's Address ) '�` ._`.�" .., 70.�:C 5i:.
1 cart'fy that 1 have read this application and state shot the "2 + Total Fee
above information is correct. I agree to comply with all County
ordinonces and State laws relating to building construction,and n
hereby authorize representatives of this County to enter upon..'s _4,. I ^,__.,___. _ _. -•, - ,
the o ve-me oned P�,openy for inspection purposes. { SEE REVERSE FOR EXPLANATORY LANGUAGE
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