HomeMy Public PortalAbout9000 GARIBALDI AVE_Grading__ WORKERS'COMPENSATION DECLARATION 76A641 T
APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self insure, 200053 DPW 8/89 (
or a certificate of Workers' Compensation Insurance, or a cer-
tified copy tlgreof.(Sec. 3800, Lab. C,) COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY
Policy Ndf!=Kw�/�q:..-"Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
SITE
Certified copy is filed with the_caynty building inspection ADDRESS` LOCALITY d
dep rtm n1. . r `-��-•�«� 10T,- O
l ..
fl ✓ x � NUMBERS BLOCK NEAREST ('
Date Applicant µr CROSS STREET W
TRACT
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER + DISTRICT NO. MAP NO. STATE HWY. PROCESSED BY
COMPENSATION INSURANCE YES❑ NO ❑ 1Y
OWNER CUBIC YDS.
(This section need not be completed if the work involved by MAIL HANDLED:
the permit is for one hundred dollars($100)or less.) ADDRESSTEL a
I certify that in the performance of the work for which this per- CITY NO. USE ZONE SPECIAL w
mit is issued, I shall not employ any person in any manner so as STATE CONDITIONS
to become subject to the Workers'Compensation Laws. ENGINEER- REG. NO.
MAIL
Date Applicant ADDRESS 2
NOTICE TO APPLICANT:If, after makingthis Certificate of Ex- TEL.
CITY NO.
emption, you should become subject to the Workers'Compen- GRADING r T L. -i; FINAL BY
sation provisions of the Labor Code, you must forthwith comply CONTRACTOR ' �� 'tom DATE
with such provisions or this permit shall be deemed revoked.
ADDRESS
LICENSED CONTRACTORS DECLARATION
I"hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code(,and my license is In full force and effect.
License Number ' r r Lic.Class
Contractors Date
CHECK IF SUPERVISED GRADING
❑ 1 am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business TEL.
and Professions Code). ADDRESS N •
SURETY$ 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`
fessions Code): FILED 8Y
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
❑ 1, as owner of the property, am exclusively contracting TIME LIMIT:
with licensed contractors to construct the project (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY:
I hereby affirm that there is a construction lending agency for EXTENDED TO: BY:
the performance of the work for which this permit is issued(Sec.
3097, Civ. C.).
P.C. Fee$ Permit Fee
Lender's Name
Issuance Fee
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
ordinancesfi+d State laws relating to building construction,and
herebiA6th-ori4 representatives of this County 10 enter upon
thef rbove;m boned perty for inspection-pu poses!' SEE REVERSE FOR EXPLANATORY LANGUAGE
Lap[__Signature of Permittee Date