HomeMy Public PortalAbout10305 LA ROSA DR_Grading__ WORKirm thaM have aIONDECLARATION CE
APPLICATION FOR GRADING PERMIT ,
76 64 (REV. 2-60)
I hereby affirm that I have a certificate of consent to self
insure,or a certificate(It Workers'Compensation Insurance,Or
a certified co y theerreoof.(Sec. 3800, Lab.C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy
Macompany y.
PloCeltifiecl copy is hereby furnished. FOR APPLICANT TO FILL IN SITE
/ ADDRESS
r] Certified copy is filed with the county building inspection SITE L� G.S..A,
department. A ESE �/ LOCALITYLOT
Date Applicant NUMBERS / BLOCK NEAREST
CROSSSTREET 1177
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT OIS ICT N MAP NO. STATE HWY. PROCE BY
COMPENSATION INSURANCE NUMBER S S(�
0 0 VE ❑ O
/ b�`+� E�-r/ Cp
(This section need not be 'completed If the WOIk involved OWNER CUBIC YDS.
MAIL �� HANDLED: a
by the permit is for one hundred dollars (3100) or less.) /yL 6� /�/</.q-Nj� -^/�'y jL/DO O
ADDRE S .�J�i /'
1 certify that in the performance of the work for which this CITY ���f'r«A" NO /�2e
permit is issued, I shall not employ any person in any manner USE ONE SPECIAL
cc
[� STATE CONDITIONS 0
so as to become subject to the Workers' Compensation Laws. ENGIN /! V� REG. NO. F
U
Date Applicant MAIL O a
NOTICE TO APPLICANT: If, after making this Certificate of CITY /'+' NOL l� U)
Exemption, you should become subject to the Workers' '"� Z
Compensation provisions of the Labor Code, you must forth- GRADING TEL. / FINAL BY
with comply with such provisions or this permit shall be CONTRACTOR HT-/ NO. 7f/7 � �/ DATE
deemed revoked. ADDRESS
LICENSED CONTRACTORS DECLARATION PROPO ED USE OF GRADED SIMS) VALIDATION
I hereby affirm that 1 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.
License Numb Lia.Class / rUJ 9'
:ontrac[or ` Date � Z7 C3 CHECK IFSUPERVISED GRADINGLS_ �e230,4A
SIGNATOR
In i am exempt from the licensing requirements as I am a OF APP AN e o e e
1 8
licensed architect or a registered professional engineer AD({KEC —sy
acting in my professional capacity (Section 7051, Bug- �e 2'° 4 7 0 0 0
iness and Professions Code). SURETY $ BOND ,
BOND NO.
Lic.or Reg. No. Date SURETY V )°.° 4 7 0,_0 0COMPANU
HOME OWNER-BUILDER DECLARATION DATE RECD O S.2 7—8 3
FILED BY
I 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
F11, 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
tion 7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting TIME LIMIT: 223015A
with licensed contractors to construct the project EXTENDED TO: BY: # e e e e - 4
(Section 7044, Business and Professions Code). I I I .
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: 2 - 480.50
1 hereby affirm that there is a construction lending agency
for the performance of the work for which thisp ermit is O -
issued(Sec. 3097,Civ. C.). P.C. Fee$ d Permit Fee 'O•° 4 8 0'5 0 5
Lender's Name
Lender's Address Issuance Fee !=' O 5 2.7—'8.3
1 certify that 1 have read this application and state that the Total Fee �D
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 t above-mentro o for ins ecti uses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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lSignalure qffermittx
Date