HomeMy Public PortalAbout5827 ENCINITA AVE_Grading__ WORKERS' F.NSA'I'ION DECLANA'PION :y 76Aal. APP TION FOR'GRADING`PERMIT� `,- -•- i� b
I hereby affirm that o certificate of consent to self insure, -CE 807(REV. 2:80) 10180 ..
or a certificate of Wo ri Compensation Insurance, or a cer- -
efied copy thereof(Sec. 3800. Lab. C.) COUNTY OF LOS ANGELES
Policy No..Company FMIRM°'F�-j TiJ5L1 AMC') C�'• _ _ '=.� WILDING AND SAFETIL•,,Y�•
IqI Certified copy is.hereby furnished. + FOR APPLICANT TO FILL IN ADDRESS s •( '
E . � SITE
Certified copy is filed with the county building inspection ADDRESS .,. Z Lv A7/ LOCALITY
department. LOT I - _
NUMBERS BLOCK NEAREST
Dalt q�pplicont SI E'�'-C i1 C�TII� /� CROSS STREET ; a
. TRACT O
ER S D 1�• DISTRICT
'; :• CERTIFICATE OF EXEMPTION FROM WORKERS' NUMB - - rq,y I f_
x COMPENSATION INSURANCE.' I ,9� �k t.1/'1 , YES❑ NO U
' •.... . )' T OWNER W
1 CUBIC S. IL
(This section need not M completed If Ilii work Involvid by ) MAIL O rrt�0 /^ G �/, HANDLED:
the permff is For one hundred dollars($100)or less.) ' ADDRESS -
I Icertify that in the performance of the work for which this per- CITY sixr/f� NO. )uSE j9NE 7SPECIAL-
mil is issued,I shall not employ any person in any manner so as '1 n ��L STATE !t /'[ ONDITIONS
ENGINEER /] REG.NO. CF. G
to become subject to the Workers-Compensation Laws. MAIL
ate Applicant - ADDRESS Wi b 4%ao
;NOTICE TO APPLICANT:If,after making this Cemificate of Comp Es- CITY jtaj NO
emption, you should become subject to the Workers'Compen- -
TE
cation provisions of the Labor Code, you must forthwith comply CONDI ACTOR NO. FINAL'
BY___
with such provisions or this permit sholl be deemed revoked. DATE
LICENSED CONTRACTORS DFCLARA'I'ION; ADDRESS y 90
I hereby affirm that I am licensed under provisions of Chapter 9 1 PROPOSED USE OF GRADED SITE(S) - - -- VALIDATIO
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force qpd effeste;ga
License Number S3�N- 1 L .Class 3 6 YI• Cb
Can>� u
to •�t 3/ ., - .._ra .1033000
CHECK IF SUPERVISED GR NG- 3 a a a si +
1 am exempt from the licensing requirements as I am a SIGNATURE -
licensed architect or a registered professional engineer OF APPLICANT
s . acting in my professional capacity (Section 7051, Business ADDRESS ~I 'Rc TEt' - ' - . - ..._ -_- _ l'�>. ( T.23-88
and Professions Code). •! R0. c t - - - z
SURETY S BOND �•`� j j.
Lic.or Reg.No. Date BOND NO. -- -
l
E HOME OWNER-BUILDER DECLARATION S SURETY
COMPANY
I hereby affirm that 1 am exempt from the Contractor's license GATE CD
Law for the following reason(Section 7031.5, BusineiRE
s and Pro- FREE BY
RE
Jessiomt Code):
CASH RECD DATE
y
1, as owner of the property, or my employees with wages , DEPOSIT S BY FILED - '� "----- �- — -- -- t71rY 1•� -. .._ _ .
_- as their sole compensation, will do the work and the s+ruc- THIS IS A LIMITED TIME PERMIT3W WAD
t, lure is not intended ar offered for sale (Section 7044, -- .•----L
Business and Professions Code). ' - Al.WORK AUTHORIZED MUST BE COMPLETED BY _ + • M
1, as owner of the property, am exclusively contracting ( TIME LIMIT: f TTA. 340.50
_ with licensed contractors to construct the project (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY f; EXTENDED TO: BY: + _ /y���yM� •Fy�s
_- ..... _ _. Vf47 +�._ ._
hereby affirm that there is a construction lending agency for s00EXTENDED TO: BY: I '
the performance of the work for which this permit is issued(sec _,
3097, Civ. C.). P.C. Fee f :• Permit Fes ' _ _._ -. - ��- — • .
Q* .4 \i.;°` ` - `�� ..;.000Q-ON �� 7/14/89
'lender's Name � � � �� •\ -
. ; a ,lssuanceF
See ,r�- i .� � �7
Lender's Address 1F1:-j fi`i.. 8L51
rt •t ., `
-st';
I cmPry that I have read this application and state that the h Total Fee
above information is correct. I agree to comply with all County -
ordinances and State laws relating to building construction,and ' iI
hereby authorize representatives of this County to enter upon
the ve-me ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
YCK� s r — 7/1, ta�