HomeMy Public PortalAbout9823 HOWLAND DR_Grading__ WORKERS'COAIPFNSA'I ION DECLARATION 76A641T
I hereby affirm that I have o certificate of consent to self insure, CE 807(REV. 2-80) ID/BD - APPLICATION FOR- GRADING PERMIT'
or'a certificate of Workers'Compensation Insurance, or o car-
tified.copy thereof(Sec. 3800, Lab. .) -
PclicyN�za� Company M4SII(417 ��r—u,,4 A COUNTY OF l05 ANGELES BUILDING AND SAFETY
SITE �•
Certified copy Is hereby furnished. FOR APPLICANT TO PILL IN ADDRESS O
7d/t�(.3 �Y7WlaH� Q �
❑ Certified copy is filed With the county building ir• 7-e zOk C 144 LOCALITY
nspection SITE ADDRESS v
departmeppntry. - _ ln� LOT
Date YA Applicant hard /(LC. ®�p10 S[.I✓. NUMBERS BLOCK ' CROSSSTREETC
TRACT al$iRlCi NO. MAP NO. STATE HWY. SSED BY U
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER _ ��� VES❑ N, ❑ W
COMPENSATION INSURANCE 6
OWNER /SCn-1 Q✓i CUBIC YDS. to
(This section need not be completed If the work involved by AMAIL DDRESS .550 G • h'ILilI? .54,*/O/ lambr4. HANDLED: ?
the permit is for one hundred dollars ($100)or less.)
qq TEL.
I certify that in the performance of the work for which this per- CITY A/ham b,-a- NO. USE ZONE SPECIAL
mit is issued, I shall not employ any person in any manner so as STATE CONDITIONS
to become subject to the Workers'Compensation Laws. ENGINEER REG. NO.
MAIL
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- TEL'
emption, you should become subject to the Workers'Compen- CITY NO.
sation provisions of the Labor Code,you must forthwith comply GRADING TEL. Z
yy� .71CONTRACTORSFINAL BY
with such provisions or this permit sholl be deemed revoked.' CONTRACTOR S NO. DATE p /�
/Dlydt F ,QoSr�/fr) S'f'• Tiitnp/z �,' O
LICENSED CONTRACTORS DECLAR A"PADDREss
ION '
Thereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full)force and effect. l�
License Number a(eJ Lic.Class `-U /
Ward rrae V
Contractor .O/"ID Dote 9-�`
CHECK IF SUPERVISED GRADING � -
❑ I am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineerOF APPLICANT
acting in my professional capacity (Section 7051, Business ADDRESS TEL
and Professions Code). NO.
SURETY$ BOND
Lic.or Reg.No. Date BOND - NO.
HOME OWNER.BUILDF-R DECLARATION SURETY
I hereby affirm that I am exempt from the Contractor's License COMPANY
Low for the following reason (Section 7031.5, Business and Pro- DATE RECD
fessions Code)' FILED BY '
CASH RECD -.DATE ,
❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY i F TIED
as their sole compensation, will do the work and the strut- THIS IS A LIMITED TIME PERMIT ` 7 168.75
lure is not intended or offered for sale (Section 7044, - _ ♦ �L�+ - -
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY 1` iTGI 1J pp
❑ I, as owner of the property, am exclusively contracting -� .. TOTAL Z6V A.75
with licensed contractors to construct the project (Section TIME LIMIT: 7 L.I�pp
7044, Business and Professions Code). GTIGM 163.75
CONS'TRUCT'ION LENDING AGENCY EXTENDED TO: BY: -
I hereby affirm that there is a construction lending agency for CHANGE .QO
the performance of the work for which this permit is issued(Sec. EKTENDED TO: .BV: -
3097, Civ. C.). 1A1 V0_;0 . ... .•LCL r�
P.C. Fee $ Permit Fee 7- ' OOOO-0001"" 9/ '792
Lender's Name gg ,1 1! _
Lender's Address i-----e.`Fee vi+p7 7J 5397 1 AM�-9:46V
1 certify that I have read this application and state that the Total Fge /9p x—�� -
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,and
here uthorize repr sen tatives of this County to enter upon
the e-mention property for inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Iz ._C6 -
Si nr ermft�e Date