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HomeMy Public PortalAbout10546 LIVE OAK AVE_Grading__ WORKI?RS' have a c SA'certificate U consent se 76A641 APPLICATION FOR GRADING PERMIT I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80) 1080 or 9 certificate of Workers' Compensation Insurance, or a cer- 19 tified copy hereof (Sec. 3800, Lab. C. COUNTY OF L& ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN SITE PY Y ADDRESS tZ . Certified copy is filed with the county building inspection SITE ©ADDRESS i " '_, LOCALITY V department. LOT NEAREST W NUMBERS ( BLOCK Date i' Applicant CROSS STREET J TRACT DlsTelcT No. MAP NO. STATE HWY. PROCESSED BY LL CERTIFICATE OF F•:XF.S1P'I'ION EKON WORKI{RS• NUMBER "* � -- YES ❑ NO ❑ Ir INSL'RANCF: OWNER CUBIC YDS. 4 (This section need not be completed if the work involved by MAIL T HANDLED: the permit is for one hundred dollars ($100)or less.) ADDRESS TEL _ I certify that in the performance of the work for which this per- CITY NO. USE ZONE SPECIAL F mit is issued, I shall not employ any person in any manner so as STATE CONDITION ENGINEER 77 REG. NO. to become subject to the Workers'Compensation Laws, MAIL Date Applicant ADDRESS TEL NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITY NO. emption, you should become subject to the Workers'Compen- GRADING - TEL. FINAL BY sation provisions of the Labor Code, you must forthwith comply CONTRACTOR NO. with such provisions or this permit shall be deemed revoked. DATE ADDRESS LICENSED CONTRACTORS DF.CLAKA FION I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number Lic.Class Contractor Date CHECK IF SUPERVISED GRADING ❑ I am exempt from the licensing requirements as I am a SIGNATURE licensed architect or a registered professional engineer OF APPLICANT acting in my professional capacity (Section 7051, Business TEL. and Professions Code). ADDRESS NO. SURETY$ BOND Lic.or Reg. No. Date BOND NO. HOME OWNER-BUILDER DECLARATION SURETY I hereby affirm that I am exempt from the Contractor's license COMPANYDATE RECD Low for the following reason (Section 7031.5, Business and Pro- FILED BY fessions Code): CASH REC'D 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 the performance of the work for which this permit is issued(Sec. EXTENDED TO: BY: 3097, Civ. C.). P.C. Fee $ j 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