HomeMy Public PortalAbout5957 ENCINITA AVE_Grading__ CI.ARA
WORKERS' fici ciN rtifi ole of consent
se CF 807(REV. 2-801 10/80 APPLICATION ION FOR {GRADING ! ERNON Y
i hereby affirm Ihot I have o certificate of consent to self insure, ,
or a certificate of Workers' Compensolion Insurance, or o cer-
tified copy thereof (Sec. 3800, Lob, C.) COUNTY OF l05 ANGELES BUILDING AND SAFETY
Policy No. ' . Company
❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN SITE C' �
Py' Y L ADDRESS c� �d/ _ p
' SITE / /J t -A a
❑ Certified copy is filed with the county building inspection ADD J ' �I LOCALITY C7
department. LOT NEAREST S
Date Applicant NUMBERS BLOCK CROSS STREET C)
TRACT i
CERTIFICATE OF(EXEMPTION FROM WORKERS' NUMBER DISTRICT_til). MAP NO. STATE tWV. EBSED BY 4U
COAIPF.NSATION INSURANCE OWNER (-I/`f I^TF1 '� '�� VES❑ NO ��T�� 4
CUBIC YDS. N
(This section need not be completed if the work Involved by MAIL /n� HANDLED: 2
the permit Is for one hundred dollars(SI08)or less.) ADDRESS d &-X Z. 3 ,
TEL. -
- . DS
I certify that in the performance of the work for which this per- CITY .� NOUSE ZONE SPECIAL '
mit is issued, I shall not employ any person in any manner so as STATE CONDITIONS
ENGINEER REG. NO.
to become subject to the Workers`S'ompensation Laws, MAIL 4
Date Applicant G•-✓'�.2�1� ADDRESS
NOTICE TO APPLICANT:if, after making this Certificate of Ex- CITY TEL.
emption, you should become subject to the Workers'Compen-
sation provisions of the Labor Code,you must forthwith comply GRADING TEL. FINAL BV •:f Li_, a:t1=15
with such provisions ar this permit shall be deemed revoked. CONTRACTOR NO. DATE ..L� - -
P P ADDRESS �-�'� `•� 1 ITEMS
LICENSED CONTRACTORS DECLARATION `,I i. �
PROPOSED USE OF GRADED SITE(S) VALIbATIONI830 a 1F;
I hereby affirm that I am licensed under provisions of Chapter 9 � � -
(commencing with Section 7000) of Division 3 of the Business (-t7EC.Y16LI,1 c
N S F -.a D'��c� Cg7lrtG Fc .1
and Professions Code, and my license is in full force and effect. KANDE
!111
License Number Lic.Class
Contractor Date
C!UC!G-OCt�1❑ 9f i2/Y4• CHECK IF SUPERVISED GRADING -
I am exempt from the licensing requirements as ]-am a SIGNATURE 1�' t �t
licensed architect or a registered professional engineer OF APPLICANT r:42 1 i= 0: 7
acting in my professional capacity (Section 7051, Business ADDRESS - TEL. -
and-Professions Code). I NO.
SURETY S BOND
Lic.or Reg.No. Date BOND t NO.
HOME OWNER-BUILDER DECLARATION SURETY t
I hereby affirm that I am exempt from the Contractor's License COMPANY
Law for the following reason(Section 7031.5, Business and Pro- DATE RECD
fessions Code): FILED BY
CASH C'D DATE
❑ I, as owner of the property, or my employees with wages DEPOSITS' '�By FILED '
as their sole compensation, will do the work and the struc- THIS I$ A LIMITED TIME PERMIT
sure is not intended or offered for sale (Section 7044, - ,
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY '
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Section TIME LIMIT:
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: '
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued(Sec. EXTENDED TO: BY:
3097, Civ. C.).
y! � P.C. Fee $' Permit Fee ,
Lender's Name ZyU
lisuanca Fee `Y
Lender's Address
I certify that I have read this application and state that the Total Fee
above information is correct. I agree to comply with oil County
ordinances and State lows reldting to building construction,and
hereby authorize representatives of this County to enter upon
the ve-m ntioned property for ins c11 p `sas. SITE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dote