HomeMy Public PortalAbout10300 KEY WEST ST_Grading__ WORKERS'COMPENSATION DECLARATION 76A641T
I hereby affirm that I have a certificate of consent to self CE 807 (REV.2-80) APPLICATION FOR GRADING PERMIT
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 ITE l/ y� �y
Certified copy is hereby furnished. FOR APPLICAN�T�T/O FIL�L`IN � ADDRESSO2�`�� KE k1�s/ 5
Certified copy is filed with the county building inspection SAID DRESS t✓VG-S% �� ' LOCALITY LOr5/—/=j Z2 L'z/
department. _ /T e
Date Applicant NOUMBERS � r`S C,Cy NEAREST �� 5 y�Y•e ,
/ CROSS STREET � �
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER /a 73 DISTRI�CTgO. MAP NO. STATE HWY. PROCESSED BY
COMPENSATION INSURANCE 7•YD ` -0/0 YES ❑ NO 0(T5"
(This section need not be completed if the work involved OwN E - moi/ CUBIC YDS S
MAIL //. HANDL D?*
by the permit is for one hundred dollars ($100) or less.) ADDRESS`7ls /�i`�G i�/� L�'/Y� ago d
_
TEL.,— y 9_ O
I certify that in the performance of the work for which this CITY f7.C��i?�'(� NO. USE ONg SPECIAL V
permit is issued, I shall not employ any person in any manner STATE CONDITIONS
so as to becoe subject to the Workers' Compensation Laws. ENG / /�J/ REG. NO. O
DMAIL Z- I'Y // 1�`� ~
Date Applicant D ES -��1 SP1 0
NOTI O APPLICANT: If, after kin th' �ificate of / TEL. LU
Exemption, you should become Z ubieet to the Workers'
CITY G NO. � �'
BY Z
TEL. FINAL
Compensation provisions of the Labor Code, you must forth- GRADING / _
with comply with such provisions or-this permit shall be CONTRACTO /1_-m�- NO. DATE i
deemed revoked. ADDRESS 7V59;7_=
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. / 2 2 4 G.6 A'
License NumberZ� L Lic.Class �/
/ ''/ _ # 0 0 0 0 1 8
�i 1^/ J 4ate CHECK IF SUPERVISED GRADING
Contractor � iG-b/1.� 8 85
SIGNAT
o F �- 1_'704 , QAO
I am exempt from the licensing requirements as I a--- a _
licensed architect or a registered professional engineer ADDRE f4 � �o���O 0
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). SURETBOND Y $ D
NO. 2Q� 0����5
Lic.or Reg.No. Date SURETY
COMPANY ° 3 9 5 0 0
HOME OWNER-BUILDER DECLARATION FILED BYC D 209-83
1 hereby affirm that I am exempt from the Contractor's CASH RECD DATE
License Law for the following 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
IP/(Section 7044, Business and Professions Code). TIME LIMIT: ;22405A
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). EXTENDED TO: BY: • e o • o 4
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: e430,50
1 hereby affirm that there is a construction lending agency 4,3050x0
for the performance of the work fo which this permit is
issued(Sec. 30.97,CiZ.).�f/j1�����1,� C P.C. Fee$ Cr� Permit Fee 12A W
Lender's Name LL�� �l, //���� (ten Q 7. Q$—8 5
Lender's Address�l7 � /i✓/�S�i/J� a�!%�/ �►W Issuance Fee Ubu iJ
I certify that I have read this application and state that the Total Fee SQ
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 pr ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of E mittee ' to