HomeMy Public PortalAbout9904 LAS TUNAS DR_Grading__ WORKERS'COMPENSATION DECLARATION 7GA641T
CE 807 (REV.2-80) APPLICATION FOR` GRADING PERMIT
I 'hereby affirm that I have.a certificate of consent!,to self
j 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
I
SITE 99`oy-/o
❑ Certified copy is hereby furnished. FORAPPLICANTTO FILL IN Q gDDRESS
j ❑ Certified copy is filed with the county building insp=action SITDRESS� 'r W1 ��U��S c LOCALITY `
department. LOT
Date Applicant NUMBERS BLOCK NEAREST
CROSS STREET
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT
NUMBER DIST CT NO. MAP NO. STATE HWY. P ED By
COMPENSATION INSURANCE " 26
Y
'/ ❑ O ❑
�.(This section need not be completed if the work involved OWNER _40 / CUBIC YDS.
MAIL HANDLED:
by the permit is for one hundred ddllars (5100) or )ess.)
ADDRESS L !2 � G� 0-
I certify that in the performance of the work for which this CITY �"/ NOL...Gn—U U O
permit is issued, I shall not employ any person in any manner
USE ONE SPECIAL U
STATE 2, CONDITIONS
so.as to become subject to the Workers' Compensation Laws. ENGINEER `! /,R,E,G.lN,O'.,,,, ZsZSs'` O
I MAIL C, ' /1 daoi%� �-
I Date Applicant ADORE U
NOTICE TO APPLICANT: If, after making this Certiffcat;! of CITY EL.�G LU
Exemption, you should become subject to the Workers' 0. A•'
Compensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL BY to
with comply with such provisions or this permit shall be CONTRACTOR NO. DATE
I deemed revoked. ADDRESS
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I I hereby affirm that 1 am licensed under provisions of Chapter
J 9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force aid 2687 0 A
effect.
ILicense Number Lic.Class #•• • •.•
(
CHECK IF SUPERVISED GRADING ❑Contractor Date ?_ 1 -
3 3 Q 0 0
_ SIGNATURE
I U El- I am exempt from the licensing requirements as I amOF APPLICANT • •�a 3 3 Q O O
licensed architect or a registered professional engineer. TEL.
acting in my professional capacity (Section 7051, Bug- ADDRESS NO. 0 1L1 6-87
mess and Professions Code). I SURETY$ BOND
BOND NO.
Lic.or Reg.No. Date SURETY
} COMPANY
I HOME OWNER-BUILDER DECLARATION DATE RECD
FILED BY
II hereby affirm that I am exempt from the Contractor'g CASH RECD DATE
;License Law for the following reason (Section 7031.5, Bus,!,- DEPOSIT$ BY FILED
ness and Professions Code): THIS IS A LIMITED TIME PERMIT
1❑ 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).
f❑ 1, as owner of the TIME LIMIT:
I property, am exclusively contractingq
with licensed contractors to construct the project; 9 �,5 A
(Section 7044, Business and Professions Code). EXTENDED TO: BY:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agen4 EXTENDED TO: - BY: # • • • •,1 8
I for the performance of the work for which this permit,is
j issued(Sec. 3097,Civ.C.). ` P.C. Fee$ 3Permit Fee 330 - 34050
(
Lender's Name �j =
Lender's Address Issuance Fee V • • 3 4(1 5 0 6
I certify that I have read this application and state that the Total Fee0 304-88
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
up h above-mentn2gprpperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE