HomeMy Public PortalAbout10815 FREER ST_Grading__ v- that have certificate" -v.• o " o •-,•.-.s.. CE 807 REV. 2-80) 10/80 APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a of consent to self insure, (
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
❑ Certified copy is hereby furnished. ;: FOR APPLICANT TO FILL IN 517E
ADDRESS .
-G Certified copy is filed with the county building inSITE
spection ADDRESS LOCALITY }
department. ' LOT O
Date Applicant NUMBERS BLOCK CROSSSSTREET v
TRACT w
CERTIFICATE,OF EXEMPTION FROM WORKERS' NUMBER
DISTRICT NO.- MAP NO. STATE HWY. PROCESSED BY J
YES❑ NO ❑
COI•iPENSATION INSURANCE >_OWNER CUBIC YDS. Uf
(This section need not be completed if the work involved by MAIL HANDLED: Q,gDDRESS �
the permit is for one hundred dollars ($100)or less.) 0
TEL. C-
I certify that in the performance of the work for which this per- CITY NO- USE ZONE SPECIAL
mit is issued, I shall not y an employ manner so as STATE CONDITIONS ,?
y person in any `
ENGINEER REG. NO.
to become subject to the Workers'Compensation Laws. MAIL
Date Applicant ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- TEL.
CITY NO.
emption, you should become subject to the Workers'Compen- GRADING TEL. FINAL BY
sation provisions of the Labor Code, you must forthwith comply CONTRACTOR NO. DATE
with such provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license is in full force and effect.
License Number Lic.Class '
Contractor Date ❑ y s u
CHECK IF SUPERVISED GRADING
❑ I am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business ADDRESS TEL.
and Professions Code). NO.
SURETY$ BOND
Lic. or Reg. No. Date BOND NO.
HOME OWNER-BUILDER DECLARATION SURETY A _.
I hereby affirm that I am exempt from the Contractor's License COMPANY
DATE RECD •-
Law for the following reason (Section 7031.5, Business and Pro- FILED RE
fessions Code): BY
CASH RECD DATE
❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED
as their sole compensation, will do the work and the struc-
ture 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:
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
Lender's Address Issuance Fee
certify that I have read this application and state that the Total Fee
above information is correct.1 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 e: