HomeMy Public PortalAbout5825 ENCINITA AVE_Grading__ WORKERS'COMPENSATION DECLARAT ION
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I hereby affirm that I have a certificate of consent to self insure, •CE 807(REV. 2:00) 10/00 Y91r 1("6�'b/91 ®151 P®IA �91APV®�O�1�Y ,I("IG Yi909�II r
or a certificate of-Workers' Compensation Insurance, or a cer.
tified copy thereof (Sec. 3800, Lob. C)
F�'�Mad 1 TnISJ�Atx1C0 �J, COUNTY Of LOS ANGELES BUILDING AND SAFETY ,
Policy No. Company
® Certified copy is hereby furnished. FOR APPLICANT TC FILL IN SITE nn •�.w s
ADDRESS
SITE
\ ElCertified copy is filed wi lh the county building inspection ADDRESS • Z L.///F• LOCALITY D
department. ` II LOT fl
Date Applicant SAW;-0i CMEL\r NUMBERS �� BLOCK CROSSSTREETC
TRACT DISTRICT NO. P O. EMWY, PROLE D Y F
G
CERTIFICATE E EXEMPTION FRONT 14'OHKFH$' NUMBER 0 J r J(� ! � LL
1 `
COMPENSATION INSURANCE ��'' / L L VES ❑ NO
' OWNER 0'/ �JLI LI19 CUBIC YDS, O
This section need not be completed if the work Involved by MAIL it HANDLED: a
the permit Is for one hundred dollars(6100)or less.) ADDRESS -p r /'GYCJ j" ' Z /- ¢J•S
``-- EL.
I certify that in the performance of the work for which this per- CITY & �` //' - —4, NO. /8 (y USE ?NE SPECIAL
mit is issued, I shall not employ any person in any manner so as ENGINEER fZ_S cS'//4h STATE
ENO d USE/
t-- CONDITIONS
to become subject to The Workers'Compensation Laws.
MAIL
le
TEL
[`���pDaApplicant ADDRESS 0 /h
$ NOTICE TO APPLICANT:If, after making This Certificate of Ex- CITY /-4 _N
emption, you should become subject to the Workers Compen- GRADING TEL, FINAL BY
cation provisions of the Labor Code, you must forthwith comply CONTRACTOR NO. DATE
with such provisions or this permit shall be deemed revoked. O 9O
LICENSEU CONTR AC'1'ONS DELLA NA'T'ION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATIeO
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force qLT%effeSto;go ,
License Num er S7*1 � L .Class t I' W # e e a
ContractorC ate rl�t 1��� 3 3 0 0 0
CHECK IF SUPERVISED GR NG _ ___ Saxe 3 3 0.010 X0
❑ I am exempt from the licensing requirements as I am a SIGNATURE ,r, - -
licensed architect or a registered professional engineer OFAPPLICANT I`1 23"8$
acting in my professional capacity (Section 7051, Business ADDRESS
and Professions Code). _
SURETY E BOND
Lic.or Reg. No. Date BOND NO. _ . ....................................
HOME OWNER-BUILDER DECLARATION SURETY
COMPANY
I hereby affirm that I am exempt from the Contractor's License
TE
Law for the following reason(Section 7031.5, Business and Pro- FLED BY EC'D 4 4
` jessions Code): CASH RECD DATE, ACCT.AV
❑ 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- - .- 3307 .-.... - 340.50
ture is not intended ar offered for sale (Section 7044, THIS IS A LIMITED TIME PERMIT
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY 1 ITEMS
❑ I, as owner of the property, am exclusively contracting TOTAL .340.50
with licensed contractors to construct the project (Section TIME LIMIT: ,
7044, Business and Professions Code).. _ CHECK 340.50 340.50
CONSTRUCTION LENDING AGENCY EXTENDED TO: By. - CHANGE • •00
I hereby affirm That there is a construction lending agency for - -
EXTENDED TO: •BV:
the performance of the work for which this permit is issued(Sec.
3097, Civ. C.). P.C. Fee 6 330-:6o Permit Fee 3 0000-0001 7G/F14/89
Issuance Fee
Lender's Name • I`.•` 7476 f API 8:51
. s '+ v y,
Lender's Address � ' • •�", � �
I certgy that I have read this application and state that the Total Fee �s
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,and '
here b authorize representatives of this County to enter upon '
he a ve-me TToned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE `
cl — UL4/P�
\ Signature Q Permitt'+e Date