HomeMy Public PortalAbout5436 ENCINITA AVE_Grading__ WORKERS' NSA'FION DECLA RA"i'ION ➢
7686417 `
I hereby affirm That certificate cerlificote of consent to self inur
se, � -CE 8a7 IREV. Z.-80} 10/F10.._.__
APPLOTION FOR'ORAbIH" d. PERMIT_
or a certificate of Workers'Compensation Insurance, or a cer. I
t F ed copy thereof (Sec. 3800, Lab. C.) COUNTY OFAOS ANGELES •cam : _ ILDING AND SAFETY-.,
H11Q •A� 1 f
Pob<y No. Company. M Tn)SL1(1/hJCJ . ._' ��:_*•.� �+, \s;,\.. - -µ
t•
Certified copy n hereby furnished - �,. FOR APPLICANT TO PILL IN SITE /��T�/ r.-
M1. •+ > - ! SITE ADDRESS Wim(
M
/ I
❑ Certified copy is-filed with the county building inspection 3 ADDRESS ,R7/ p.JCALITY V
r department - ! LOT -
Dat}0r��� I r� l
}-YL1{S�—APPlicanl •S('�N'1 �{ il CTlsill ` TR IUIBERS O.� ... _ BLOCK .. __Y <a055557�Ei. 0. _
i'• CERTIFICATE'OF FXFM1IPTION FROM WON KERS NUMBER csTR¢T NO E H V. PRCCE D Y- U-
COMPENSATION INSURANCE .� 1.. �' s JT ( - YES O NO W'.
s .. - t •>. OWNER 1-,9112 S.11 L�n_ ... 'CUBIC YDS: W
(This section need not be completed If flits work involved by MAIL ;l .HANDLED:
16ts permit is for one hundred dollars($100)or less.) ADDRESS p /C/U J^GG' G .L�'
y . . T� TEL..
['certify that in the performance of the work for which this per- -.e CITY Yr NO USE j9F1F SPECIAL
mil is issued, 1 shall not employ any person in any manner.so as $ TATE /[ ONDITIONSto - ? E
ENGINEER 7 � SicSi REG.NO. K
become subject to the Workers'Lompensation laws. '. MAIL I �+ ..�_ - ,... _ - i
Pate' Applicant- ,.•. �' ADDRESS b U -
NOTICE TO APPLICANT If,after making the CerlifKate'of Ex- -CITY J-st' NO �� u.�G�"O
emption, you should become subject to the Workers'Compen GRADING {
sation provisions of the Labor Code, you must forthwith comply. j - TEL' FI NAL- gy_.. ..
wdeemed with such provision$or this permit shall be dd revoked s CONTRACTOR NO. ATE ,y L
a - -. .. c; + ADDRESS i
-: e^ LICENSED CONTRACTORS DPCLARA'I ION,
I hereby affirm that 1 am licensed unPROPOSED USE OF GRADED SITE(S)provisions of Chapter 9 y f J -- - --- --- - . - _ VALIDATIO
(commencing with Section 7000)of Division 3 of the Business s "
and Professions Code,and my license is in full force d�fec�t.
�YI •f4o
License Num I
r 539N1 I L .Class " Ll
Conti` A - to �tl
1 . 33000
` CHECK IF SUPERVISED GR NGIt
-
❑'1 am exempt from the licensing requirements as 1 am a 7 SIGNATURE 4 .r: _ _ S '1 �Y/ '�e33 n00'-sT
licensed architect or o registered professional'engineer OF APPLI ANT
c..- acting in my professional capacity (Section 7051,-Business 'ADDRESS "% a' TEL`a j._y_J/`� .__ •�� ,n,1 1123-88 i
and Professions Code). - - - s RO. 6'a 66 'E - L
SURETY$ BOND {{
Lic or Reg No. Dare BOND - NO. -
SURETY•
' HOME OWNER-BUILDER DECLARATION' - - + -vim -•-a a < - \- .� e
} COMPANY
I hereby affirm that I am exempt from the Contractor's License .l DATE RECD "i $ f _ '`C� a
Law for the following reason(Section 7031.5;Business and Pro- •t FILED BY
c-,•—
Jessions Code): 'et - 1 ` i"k x
CASH RECD DATE_ ' 4 ryyyT•9 r _
I, as owner of the property, or my employees with wages DEPOSITS -'_--- BY - - "-- FIIFD
as then sole compensation, will do the work and the srruc- THIS IS A LIMITED TIME PERMIT... _. ,, 1 { 37"--'- -_ _^• •�
tura ;s not intended or offered for sale
(Section 7044, _g. -- _
TENS
Business and Professions Code)., _., --•`i7 - ALL WORK AUTHORIZED MUST BE COMPLETED SY i ' 1 I I L
TO
I, as owner of the property, am exclusively contracting TAI B 340
C^
With licensed contractors to construct the project (Section TIME LIMIT: - y field
s 7044, Business and Professions Code). - - - - -- ._._,... _ •�.
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: - - .,
s - "... W
I hereby affirm that there is o construction lending agency for EXTENDED i0: BY: ' - ~
ti•FTSRva .L�11rrss
the performance of the work for which this permit is issued(Sec.
3047, Civ. G). s _......
' P.C. Fee
$ .� Q Permit Fee 1 �\ 7�14�89:
'Lender's Name _
.,Issuance Few ?
Lender's Address .\_ - T i\.\�\ F -_`t"c: 76.4 V-` ..AM 31151-
Icortit,,y that I have read this application and stare that the ` Total Fee
above information is correct. I agree to comply with all County
ordinonces and State lows relating to building construction,and
hereby authorize representatives of this County to enter upon j_ _
he o ve-me 'tined ry for inspection purposes. ; SEE REVERSE FOR EXPLANATORY LANGUAGE
SI�a gc � F CIoper--._ 17/14/e�