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HomeMy Public PortalAbout8905 LAS TUNAS DR_Grading__ WORKERS'COMPENSATION DECLARATION 76A641 APPLICATION FOR GRADING PERMIT I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80) 10/80 or a certificate of Workers'Compensation Insurance, or a cer- tified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified co Is hereby furnished. FOR APPLICANT TO FILL IN SITE - PY � Y ADDRESS SITE ❑ Certified copy is filed with the county building inspection ADDRESSCALITY - department. LOT O 4 NEAREST U IN Date Applicant NRUMBERS CROSS STREET u CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER DISTRICT NO. MAP NO. STATE HWY. PROCESSED BY COMPENSATION INSURANCE YES❑ NO 0 y OWNER f Amerfea CUBIC YDS. (This section need not be completed if the work involved by MAIL HANDLED: the permit Is for one hundred dollars($100)or less.) ADDRESS 3731 Wilshire Blvd. OC> TEL. I certify that in the performance of the work for which this per- CITY LOS Afteles No.385-19013 USE ZONE SPECIAL w mit is issued, I shall not employ any person in any manner so asSTATE CONDITIONS to become subject to the Workers'Compensation Laws. ENGINEER CiVic III inerar REG. NO. 2022 MAIL Date Applicant ADDRESS 6047 NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITYNO. emption, you should become subject to the Workers'Compen- GRADING TEL. FINAL BY sation provisions of the Labor Code, you must forthwith comply CONTRALTOOM nks NO. DATE with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION ADDRESS 3731 Wilshire Blvd•y LA I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION (commencing with Section 7000) of Division 3 of the Business Homes Savings Bldg. (bank) and Professions Code,and my license is in full force and effect. License Number Lic.Class - �=t =: 1't Contractor Date ` v e`1►'♦ ( ' CHECK IF SUPERVISED GRADING ❑ I am exempt from the licensing requirements as I am a SIGNATURE ? ) licensed architect or a registered professional engineer OF APPLICANT r� acting in my professional capacity (Section 7051, Business ADDRESS TEL i !f :�f ` •�s and Professions Code). p SURETY$ BOND a:f" ` '_ v Lic.or Reg. No. Date BOND NO. HOME OWNER•BUILDER DECLARATION SURETY I hereby P affirm that I am exempt from the Contractor's License COMPANY DATE RECD Law for the following reason(Section 7031.5, Business and Pro- FILED BY fessions Code): CASH RECD DATE ❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED 9 as their sole compensation, will do the work and the struc- ture is not intended or offered for sale (Section 7044, :J Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY ❑ I, as owner of the property, am exclusively contracting Q ' with licensed contractors to construct the project (Section TIME LIMIT: 7044, Business and Professions Code). • s 1" CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: 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 - Lender's Name IssuanceFeeFee Lender's Address I certify that I have read this application and state that the Total Fee"OM 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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date (bs v' W&RKERS'COMPENSATION DECLARATION T APPLICATION FOR GRADING PERMIT (hr eby affirm�i�at I have a certificate of consent to self insure, CE CE 807 807(REV. 2-80)10/80 or a certificate of Workers'Compensation Insurance, or a cer- tified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Na., Company SITE ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 4f 1: SITE ❑ Certified copy is filed with the county building inspection ADDRESS i' LOCALITY a department. LOT NEAREST Dare f Applicant NUMBERS BLOCK CROSS STREET TRACT CERTIFICATE OF EXEMPTION FROM WORKERS' NU BER DISTRIgT NO, MAP NO. STATE HWY. PROCESSED BY LL COMPENSATION INSURANCE : �- f YES❑ NO ❑ r OWNER.... J �. /_ ;y =:• d CUBIC YDS. oe (This section need not be completed if the work Involved by MAIL HANDLED: < the permit Is for one hundred dollars($100)or less.) ADDRESS _ ,•. f o N !/ TEI, -f w........, a- CITY �/C NO ;,r^ `, . I certify that in the performance of the work for which this per- USE ZONE SPECIAL mit is issued, I shall not employ any person in any manner so as _ r STATE r CONDITIONS ! _c.. to become subject to the Workers'Compensation Laws, ENGINEER REG. NO. MAIL � •, �,. ' Date Applicant ADDRESS NOTICE TO APPLICANT:If, after makingthis Certificate of Ex- TEL. CITY'' NO.' i• .r r. _ em tion, you should become subject to the Workers'Compen- P GRADING TEL. i FINAL BY sation provisions of the Labor Code,you must forthwith comply CONTRACTOR - � �-% NO. DATE with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION ADDRESS - a I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION (commencing with Section 7000) of Division 3 of the Business , and Professions Code, and my license is in full force and effect. x Number iClass License Nu L c. CQ� Contractor � Date CHECK IF SUPERVISED GRADING ❑ I am exempt from the licensing requirements as am a SIGNATURE .� P 9 5 GNA 9 - licensed architect or a registered professional engineer OF APPLICANT acting in my professional capacity (Section 7051, Business ADDRESS and Professions Code). SURETY$ BOND Lic.or Reg.No. Date BOND NO. ,. . HOME OWNER-BUILDER DECLARATION SURETY COMPANY I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Pro- FDI ED BY RECD :1 fessions Code): CASH RECD DATE ❑ I, as owner of the property, or my employees with wages DEPOSIT,$ BY FILED as their sole compensation, will do the work and the struc- ture is not intended or offered for sale (Section 7044, Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY ` ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section TIME LIMIT: 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: 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 Lender's Name Issuance Fee Lender's Address I certify that I have read this application and state that the -- Total Fee 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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date Os : WORKERS'COMPENSATION DECLARATION 76A641 APPLICATION FOR GRADING PERMIT I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80) 10/80 or a certificate of Workers'Compensation Insurance, or a cer- tified coy thereof (Sec. 38 IILa CAA . COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N1s?� m�a�S! MXPy SITE �+ ❑ Certified copy is hereby furnished. co rp, FOR APPLICANT TO FILL IN ADDRESS Q C �sYd SITE ❑ Certified copy is filed with the co my uilding inspection ADDRESS (�CALITY departmentLOT East 161 of Lot 70 &BLbMt 71 i • NUMBERS NEAREST DateApplicant TRACT CROSS STREET NUMBER 3623 Bk. 40 P . 52 CERTIFICATE OF EXEMPTION FROMWORKERS' DISTRICT NO MAP NO STATE HWY PROCE ED BY COMPENSATION INSURANCE OWNER Home Savings of America CUBIC YDS. °�4O YES❑ NO C (This section need not be completed If the work involved by MAIL 3731 Wilshire Blvd. HANDLED: the permit Is for one hundred dollars($100)or less.) ADDRESS � /O I certify that in the performance of the work for which this per- CITY Los Angeles No 385-1900 USE ZONE SPECIAL mit is issued, I shall not employ an person in an manner so as STATE r- CONDITIONS d p y y P y ENGINEER Civic Engineer REG NO 20228 L' >� to become subject to the Workers'Compensation Laws MAIL OO Date Applicant ADDRESS 6047 Tama Ave. NOTICE TO APPLICANT: If, after making this Certificate of Ex- CITY Tarzana NO 345-5510 O emption, you should become subject to the Workers'Compen- GRADING TEL FINAL BY w sation provisions of the Labor Code, you must forthwith comply CONTRACTORHome Savings NO 385-1900 DATE (/ vai with such provisions or this permit shall be deemed revoked. O Z LICENSED CONTRACTORS DECLARATION ADDRESS 3731 Wilshire Blvd., LA — I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) L�m VALIDATION (commencing with Section 7000) of Division 3 of the Business Homes Savings Bldg. (bank) 6 and Professions Code,and my license is in full force and effect License Number'14 9119 Lic.Class, _ 3 *3069A g'?, !1�7 2 SSO .0 a Contractor ate -1 2 r J # ° 0 0 0 1 8 CHECK IF SUPERVISED GRADING ❑ I am exempt from the licensing requirements as I am a SIGNATURE 2 0 3 1 0, 00 licensed architect or a registered professional engineer OF APPLICANT p acting in my professional capacity (Section 7051, Business ADDRESS 6047 Tam a Ave NO 45-5510 "d " °,° 3 1 0 0 0 cz� and Professions Code). SURETY$ BOND Lic.or Reg. No. Date BOND NO. 0622-83 HOME OWNER-BUILDER DECLARATION SURETY I 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 CASH RE RECD DATE ❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED L 4 1 7 2 A as their sole compensation, will do the work and the struc- ture is not intended or offered for sale (Section 7044, Business and Professions Code) # o 0 0 0 0 (� ALL WORK AUTHORIZED MUST BE COMPLETED BY ❑ I, as owner of the property, am exclusively contracting 2 o320.50 with licensed contractors to construct the project (Section TIME LIMIT: 7044, Business and Professions Code). ° - 320,505 CONSTRUCTION LENDING AGENCY EXTENDED TO: BY 1 hereby affirm that there is a construction lending agency for 0 8 0 2-8 3 EXTENDED TO BY the performance of the work for which this permit is issued(Sec 3097, Civ C.). P C. Fee $ 01 Permit Fee--3/o. cnQ Lender's Name Issuance Fee Lender's Address , I certify that I have read this application and state that the Total Fee.:!% ,J!O 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,p ve- do d prop Ty f inspiec ion purposes SEE REVERSE FOREXPLANATORY LAj,VGUAGE l/' r1 ,D' 6-ZZ C Signature -of Permittee Date ©s ��L���G��%�r'lu .