HomeMy Public PortalAbout5225 FARAGO AVE_Grading__ WORKERS' DECLARA HON consent
76A641 APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80) 10180
or a certificate of Workers' Compensation Insurance, or a cer-
tified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company f
❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN SITE
PY Y ADDRESS IL
SITE 0
❑ Certified copy is filed with the county building inspection ADDRESS LOCALITY 0
department. LOT W
.a .1 Applicant NUMBERS BLOCK NEARECROSSSSTREET U.
Date
- �' TRACT LL
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER DISTRICT No. MAP NO. STATE HWY PROCESSED BY >_
COMPENSATION INSURANCE YES ❑ NO ❑
OWNER CUBIC YDS.
(This section need not be completed if the work involved by MAIL HANDLED:
the permit is for one hundred dollars ($100)or less.) ADDRESS
TEL.
LU
I certify that in the performance of the work for which this per- CITY NO. USE ZONE SPECIAL
mit is issued, I shall not employ any person in any manner so as STATE CONDITIONS
to become subject to the Workers'Compensation laws. ENGINEER REG. NO.MAIL
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- CITY NO TEL.
_
emption, you should become subject to the Workers'Compen- GRADING TEL FINAL BY
sation provisions of the Labor Code, you must forthwith comply CONTRACTOR �' w" f7, NO
with such provisions or this permit shall be deemed revoked. DATE
LICENSED CON'T'RACTORS DF.CI.ARA'I'ION ADDRESS f d
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number - r Lic.Class
Contractor 1''
Date ❑
' CHECK IF SUPERVISED GRADING
❑ I am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business ADDRESS TEL.
and Professions Code). NO.
SURETY$ BOND
Lic.or Reg. No. Date BOND NO.
HOME.OWNER-BUILDER DECLARATION SURETY
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
FILED BY
fessions Code): CASH RECD DATE
❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED y
as their sole compensation, will do the work and the strut-
ture is not intended or offered for sale (Section 7044, THIS IS A LIMITED TIME PERMIT
Business and Professions Code).
ALL WORK AUTHORIZED MUST BE COMPLETED BY
El a,
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:
I 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.). P.C. Fee $ Permit Fee
Lender's Name
Issuance Fee l.rs4'vl
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 all County
ordinances and State laws relating to building construction,and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date