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j WORKERS'COMPENSATION DECLARATION CE 907 (REV 2-801 IT ' APPLICATION FOR GROWING PERMIT
1 CE o07 `
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
I' ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE `I`"r✓L` f '�'' "''' '"Y�`"''"" ""
i ADDF ES
❑ Ce tified copy is filed with the county building inspection SITERE
LOCA'_ITY ;�-•}w
_departLn
ment. LOT $
Pale--01-�Pale--01- BLOCK Applicant NUMBER 7"�>x NEAREST
lTRACT S
/ R $fir' T R E E T
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER � , DS3;4,-T MAP N STATE HWY. PRQCESSED Bir
COMPENSATION INSURANCE- _ f�7 •;+.33 <�T Y
[(This section need not be completed if the work involved OWNER //r5 r LC CUBIC-YDS.
t b the permit is for one hundred dollars (5100) or less. MAIL i /� HANDLED a
Y P ) D E �i4 !G/cc2c1 f� �se �./ O
I certify that in the performance of the work for which this CITY <6 r/ NOL�_ U
c NE SPECIAL
permit is issued, I shall not employ any person in any manner �f+��/ STATE NS
Z, CONDITIOO
so-as to become subject to the Workers'Compensation Laws. ENGINEER PA-, /,/1 aro// REG NO
- MAI �oC C�fl AXZ /7-//n !$L J
Date Applicant L
'NOTICE TO APPLICANT-:-If, after making this Certificate•of i CIT Jh( �t/
Exemption„ you should become subject to the, Workers' N
Compensation provisions of the Labor Code, you must forth- GRADING TEL FINAL BY tr
with comply with such provisions or-this permit shall be CONTRACTOR NO DATE U
1 deemed revoked. ADDRESS
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.
License Number Lic.Class T4 ° •, °.o
CHECK IF SUPERVISED GRADING ❑ f • '
Contractor Date IGNATURE J' v
OF APPLICANT • i r
I am exempt from the licensing requirements as 1 am a TEL
J
licensed architect or a registered professional engineer TE
ADDRESS TNO
E
acting in my professional capacity (Section 7051, Bug-
iness and Professions Code). SURETY $ BOND
BOND NO
Lic.or Reg.No Date SURETY «
COMPANY
HOME OWNER-BUILDER DECLARATION DATE RECD
FILED BY
I hereby affirm that I am exempt from the Contractor's iCASH 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
❑ 1, asowner 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'
❑' 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project EXTENDED TO BY. y Cj 1,5 P
(Section 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY EXTENDED TO BY M ° • • •
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec 3097,Civ C). P C Fee$ d Permit Fee -� �. •,3 is' J
Lender's Name
Lender's Address Issuance Fee
i
I certify that I have read this application and state that the Total Fee , V v,a 1 t' .18
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
-r and hereby authorise representatives of this County to enter
u t above-men WnSo"p perry for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
+ SI¢nanire of Permittee Dile