HomeMy Public PortalAbout6032 GOLDEN WEST AVE_Grading__ I hereby affirm that I have a certificate of consent to self;nsure, CE 807 (REV. 2-80) )G%80 MIT-r LI`Iliw ft I ivl'r $'L-Qr► %,$8if1L091 E'7 r 16RdIIIIll@ t
or a certificate of Workers'Compensation Insurance, of a cer-
tified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Noompany •:� t �
1. C—Pc10 1 '1' tJs f�wElL+iA FOR APPLICANT O FILL IN SITE
ADDRESS
❑ Certified co a ere furnis a
SITE
® Certified copy is filed it b �Iding inspection ADDRESS b� - G d�C(!+) _ LOCALITY
department. LOT NEAREST NUMBERS BLOCK
Date 3 qApplicant TRACT CROSS STREET
hC R�IFICA�"E OF EXEMPTION FR WO KERS' NUMBER DISTRICT MAP NO. ' STATE HWY. D BY
COMPENSATION INSURANCE. . YES 0 NO
OWNER V CUBIC YDS.
(This section need not be completed if the work involved by MAIL !! HANDLED:
the permit is for one hundred dollars($100)or less.) ADDRESS C a 'y - -
TEL
1 certify that in the performance of the work for which this per-- CITY p_ NO. USE ZONE SPECIAL -/ - (
mit is issued,1 shall not employ any person in any manner so as STATE CONDITIONS _
to become subject to the Workers' m cation Laws. ENGINEER e !� nn`;r REG. NO.
MAIL
Date Applicant
tTPPlicant �— ADDRESS C u _. _ - _,._..35 --. - ..� ~• ';
NOTICE APPLICANT:If, after et
e of Ex. TEt. t
emption, you should become subl c to he ormpen_ CITY A rGG �. NO. Til-MC 4
GRADING t TEL. FINAL - BY -
sotion provisions of the labor Code, ou u farth'with::om I I
with such provisions or this permit shall be deemed revoked.Y CONTRACTOR 1 NO. G` DATE TOT AL 34-8-
LICENSED CONTRACTORS DECLARATION ADDRESS
I herebyaffirm that I om licensed under rovisions of Cha ter 9 PROPOSED-USE OF GRADED SITES) _ ATION .._
P P CHIMA -`i- . 1
(commencing with Section 7000) of Division 3 of the Business
and Professiions Code,and my license is in full force and effect. - -
it c€15s�N9uthb c.Class I �- [rl��l0-tom 4 I i��,•' I
Contra, rrom
Date r=--rte- 3570 1 AMpr 1•`4`
Jo-z 3- 7 0 CHECK IF SUPERVISED RA
❑ I am e ecensing requirements as I am a SIGNATURElicensed egistered professional engineer OFAPPLI ANT
acting in capacity (Section 7051,BusinessTEL. ------_-- .•. _.
and Professions Code). AD KESS NO ��
SURETY$ - BOND -... :,..
Lic.or Reg. No. Date BOND ' NO.
-HOMEOWNER-BUILDER DECLARATION SURETY --• -• - ='
COMPANY
I hereby off irm that I am exempt from the Contractor's i.icense
Law for the following reason(Section 7031.5, Business a,-td Pro- DATE RECD
fessions Code): FILED BY �y z
CASH RECD DATE•i.T _
❑ 1, as owner of the property, or my employees with wages DEPOSIT$ BY FILED # ---
as their sole compensation, will do the work and the strut- 3307
ture is not intended or offered for sale (Section 7044, THIS IS A LIMITED TIME PERMIT _., .___ - - _
Business and Professions Code). 1 ITEMS
ALL WORK AUTHORIZED MUST BE COMPLETED BY _. j
❑ 1, as owner of the property, am exclusively contracting TOTAL *20.ii 00
with licensed contractors to construct the project (Section TIME LIMIT:
CNEL-Y.7044, Business and Professions Code).
1001
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY:
I hereby affirm that there is a construction lending agency for EXTENDED TO: BY: ,� y •
the performance of the work for which this permit is issued(Sec. G.1 c'' �.I t•_�
3097, Civ. C.). .1 l �) C.1 roti Ly1
Olt t v( P.C. Fee E. �� Permit Fee ►-mac ' d ti fZ 3 -� � 2 ��1�T/ `
Lender's Name �l
C7
Issuance fee` O „3 t-r Ufa 7$69 1 AM 7:14'
Lender's Ad, t-4:t }k
I certify that 1 have read this application and state that the Total Fee 3 °
above information is correct. I agree to comply with all County
ordinances nd State laws relating to building construction,and _r
hereby o Il ize representatives of this County to enter upon 3> G
the tioned pro erty for inspection purposes. SEE REVERSE FOREXPLANATORY I_Ajg4jAGE ._rl ! -
Si of P t Date 4,
6� .`