HomeMy Public PortalAbout6030 GOLDEN WEST AVE_Grading__ CLARA'
by affirm
that I have a NSAficat of consentI,/y se 76A641 APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent fo self insure, CE 807(REV. 2-80)10i80
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.r _ __ZCc
Certified copy is'herebyurnish`16d '' ' '' FOR APPLICANT TO FILL IN A�oREss
IL
SITE O
Certified copy is filed witly j}e c�'%Aty building inspection ADDRESS LOCALITY V
department. LOT W
` NUMBERS BLOCK NEAREST J
Date ^^^ Applicant CROSS STREET
CERTIEICAT`E OF FIXF.MPTION FROM WORKI?RS' NUMBER DISTRICT NO. MAP W
NO. STATE HWY. PROCESSED BY
COMPENSATION INSURANCE. -- '
YES ❑ NO 1
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 f
TEL. f �
1 certify that in the performance of the work for which this per- CITY NO. USE ZONE SPECIALRCc ? 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 +4 __ ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- TEL.
CITY NO. ..:
emption, you should become subject to the Workers'Compen-
sation provisions of the Labor Code, you must forthwith comply GRADING TEL FINAL JBY
with such provisions or this permit shall be deemed revoked. CONTRACTOR NO DATE
LICENSED CONTRACTORS DF.CLARA'LION 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.
V eWf Aber .tic.Class
Contractor Date -a *-^ ❑
Elr CHECK IF SUPERVISED GRADING
I am exempt from the licensing requirements as III 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 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
DATE RECD P,
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
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
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 LANGUAGF,
Signature of Permittee Date