HomeMy Public PortalAbout6129 HART AVE_Grading__ WORKERS%COMPENSATION DECLARA'T'ION 76A641T 0 0 0 0 D
I h@reby of tim t!at'I ha:ve'o certificate of consent to self-insure, 'CE•80?(REV. 2,-80) ,0/80' APPUCQTDON FOR GRAMM PERAUY
or a certificate of Workers' Compensation Insurance, or,a cer-
tified copy thereof�((Seec. 3800, Lab. C.) " ,' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoR391++1 /Company
�— SITE C
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ell,/,;;4 /' �C�l�/1i
' SITE r �7 �, D
❑ Certified copy is filed with ih county'building inspection ADDRESS b LOCALITY C
.G°C�
de a m n. LOT . NEAREST D
Date 2 Applicant NUMBERS BLOCK CROSS STREET C
NUMBER DISTRICT NO. MAP NO. STATE HWY. CESSED BY
CERTIFICATE OF EXEMPTION FROM RKF.RS' �Or� YES❑ NO O *� LL
COMPENSATIOWINSURANCF. �"
OWNER .4-A 442f: CUBIC YDS. D
(This section need not be completed if.the work involved by MAIL //?? HANDLED: ^ -���.
the permit is for one hundred dollars($100)or less.) ADDRESS �CiZ O /a�j 4"IA F
I certify that in the performance of the work for which this per- CITY Naar/ �a a : USE ZONE ✓SPECIAL•
mit is issued, I shall not employ any person in any manner so as f STATE CONDITIONS
fo become subject to the Workers'Compensation Laws. ENGINEER REG. NO.
MAIL
Date Applicant ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITY NO.
emption, you should become subject to the Workers'.Com pen- GRADING' EOL!, _( Oji FINAL, BY
sation provisions of the.Labor Code, you must forthwith comply CONTRACTOR. NO. (.�'/�elle DATE
with such provisions or this permit shall be deemed revoked. 2
LICENSED CONTRACTORS DECLARA'T'ION ADDRESS -
I hereby affirm that I am licensed under provisions of Chapter 9, _ PROPOSED USE OF GRADED SITE(S) VALIDATION
.(commencing with Section 7000) of Division 3 of the Business CC �eL Q
and Professions Code,and my license is in fuut jforce'and effect.
APS QAOX4�
License Number 46 Lic.Class 4✓
•Contractor cJ�e
CHECK IF'SUPERVISED RADING
ElI amexempt from the licensing requirements as l dm a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business ADDRESS TEL.
and Professions Code). N
SURETY$ BOND
Lic.or Reg.-No. Date BOND NO.
HOME OWNER-BUILDER DECLARATION SURETY
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 BY
' CASH RECD DATE
AC:C�T o g
❑ as owner of the property, or my employees with-wages DEPOSIT$ BY FILED 3303 2$`.00
as their sole compensation, will do the work and the strut- THIS IS A LIMITED TIME PERMIT �r
ture is not intended or offered for sale (Section 7044, 1 ITEMS
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY
❑ 1, as owner of the property, am exclusively contracting TOTAL 264 -0101
with licensed contractors to construct the project (Section' TIME.LIMIT:
-7044, Business and Profession's'Code). CHECK
264.00
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: CHANGE .00
I'hereby affirm that there is a construction lending agency for EXTENDED TO: BY:
the performance of the work for which this permit is issued(Sec.
3097, Civ. C.). P.C. Fee$ Permit Fee 0000-0001 6./.3/96
Lender's Name 6727 1 AN 11n51
Issuance Fee27, 30
Lender's Address
• I certify that I have read this application and state that the Total Fee 0 O
abovein rmation is correct. I agree to,comply with all County
ordina els and•State laws relating to building construction,and
4thorize representatives of this County to enter upon
- entioned property for inspectio pos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
of.Permittee Date