HomeMy Public PortalAbout6022-6028 KAUFFMAN AVE_Grading__ WORKERS'COMPENSATION DECLARATION CE 867,sT ' APPLICATION FOR GRADING PERMIT
_ CE 807:{(REV.2-80), ` "
I hereby affirm that I have a certificate of consent to self
',insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof,(.Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
SITE_ .
ED Certified copy.is hereby furnished. FOR APPLICANT•TO FILL IN ADDRESS, f' tr� �C4d�lf<i tp'(• R��K -=*
;y❑ Certified copy.is filed with the county.building inspection SITE .E �`�' + `• ` ' —a LOCALITY
department. �' t
LOT 1 :t d''ll
I'Date Applicant,. NUMBERS ( .✓' BLOCK NEAREST
ROSS STREET a f
i CERTIFICATE"OF EXEMPTION FROM WORKERS" TRACT- f DISTRICT'NO:= MAP N STATE H PROCESSED Y }
NUMBER =� fJ�•, d
COMPENSATION INSURANCE y ❑ t,•,_: '
4 ; OWNER L�•� «r• �� CUBIC YDS. 0 .
,(This section need not be completed-if•the' work involved MAIL HANDLED ( V'
,by •trhhe4!permit is for one'hundred dollars ($100)^^ or less.) ADD E S1Z4. t N L -:` i `A. `:� •; J
11`'certify that.in the performs ce of;,t a work"forr�Which this CITY / r + ) NO. ( `��}.�L ty
USE�/(�Ol�}J��••� SPECIAL
,permit is issued, I shall"note ploy an ,person is manner STATE ��t 11• fJ CONDITIONS }.
so as,to become sub'ect,to th W r e o eVat nj�LaV,_ ENGINEER`•-Il � T REG. NO. --moi'„_,)S
t ' l j , p i %V✓ .`V MAIL �t� a- Q
'Date' Applicant .• � !3�. '�' � .�'•• Lr
NOTICE TO APPLICANT.:'If, after-making this Certificate of �. TE L.4�w ;��' d
Exemption, you•should'become subject •to the Workers'
CITY J. NO. !
Compensation provisions of the Labor Code,'you must forth- GRADING TEL., FINAL BY •• 1, `• LU
with•'comply with- such provisions or this- permit' shall be �•" CONTRACTOR. NO. DATE
deemed revoked. ADDRESS'
LICENSED,CONTRACTORS DECLARATION
PROPOSED USE OF GRADED SITE(S) VALIDATION
I hereby affirm that I am licensed under provisions of Chapter2P LJ NN
9 (commencing with Section 7000)-of Division 3 of the•Busi- +� / "�
nes's-and Piofessio'nsjCod�and my license is in full.,force and P M C t
e'nse 'u,mb nsic:Class ( }
1' � CHECK IF SUPERVISED GRA NG
"❑ ,
ntractor'� Date
r• t? SIGNATURE
��•
OF APPLICAN
I yam exempt.from the, licensing requirements as.I am a
licensed architect.'or•a registered professional engineer, TE
ADDRES
N �i+ •-- )iv1�,�����`,r ,13�1r
acting in my professional capacity (Section 7051, Bug:
iness and Professions Code). SURETY $ BOND
t BOND e NO.
ic.orReg.No. Date SURETY {Qil°J�rr9
COMPANY ✓�y
HOME OWNER-BUILDER DECLARATION DATE RECD (}11(�+ ►9 y,i�i:'�"
FILED BY
I hereby affirm that I am exempt from -the Contractor's CASH RECD DATE'
License Law for therfollowing'reason '(Section 7031.5,"Busi- DEPOSIT$ BY' FILED
ness.and Professions Code):, THIS IS A LIMITED TIME PERMIT '
❑ I, as owner of-the property, or- my employees•with'. ;
-wages-, as, their sole compensation„ will "do the work,, ALL WORK AUTHORIZED MUST BE COMPLETED-'BY
and. the structure•is not intended or offered for,sale
(Section 7044; Business and Professions Code). ;
TIME LIMIT: k: '
1`f '1I, as owner of the property, am exclusively contracting
with licensed contractors` to construct " the project
EXTENDED TO: BY
(Section 7044, Business and Professions Code).
m ,m 1p,{0
i' i{ ..t )i t!
CONSTRUCTION LENDING AGENCY + 1
g agency', EXTENDED;TO
I herebyBY ,
,affirm ,that there is a construction lendin a enc /
for the performance of the work for'which this permit is Permi�r,° !"I
issued, 3097,Civ.C.). P.C-' Fee'$ iF .ri try "i
-Lender's�Name
Issuance Fee
Lender's Address' w
'I ceritif that I"have read this application and state that the n�
Y, pp. 'Total'Fee
above informs tion is correctc•,I agree to-comply,with all County
ordinances fitd-StateIr
#�ws elating to building construction,
.andtlihereb t`rthorizepres ntatives ofAhis Count to nter
upcfn t e b Le- tied„' o er y insp+e�fyon')pur oss; i SEE REVERSE FOR'EXPLANATOvRY LANGUAGE ”
�; Siknature•of Permittee '-Date