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Home My Public Portal About10157 LOWER AZUSA RD_Grading__ Wok I�F�RS°�QM�: TSATION DECLARATION CE 807 T APPLICATION FOR GRADING PERMIT }'4 ��`` CE 807 (REV. 2 80) � 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 ,❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE ADDRESS Certified copy is filed with the county building inspection SITE �. `f department ADDRESSA` I � LOCALITY Date Applicant 1 fr ` NOUMBERS t BLOCK NEAREST TRA:CT-"- /t CROSS STREET CERTIFICATE OF EXEMPTION FROM WORKERS' f NUMBER f ' ' DISTRICTNO. MAP NO. STATE HWY. PROCESSED BY a. COMPENSATION INSURANCE YES ❑ NO (This section need not be completed if the work involved OWNER CUBIC YDS./- HANDLED: �'•%J � fir` �� by the permit is for one hundred dollars ($100) or less.) ADAOREss ' UJI TEL; I I certify that in the performance of the work for which this CITY NO. LIQ permit is issued, I shall not employ any person in any manner STATE CONDITIONS _, USE;ZONE SPECIAL to be7me subject to the Workers' Compensation Laws. ENGINEERso as REG. NO. MAIL Q DateApplicantADDRESS'' Lr NOTICE TO APPLICANT: If, after makin4 this Certificate of CITY NOL., 0 Exemption, you should become subject to the Workers' CL Compensation provisions of the Labor Code, you must forth- GRADING _ TEL. - FINAL BYLU with comply with such provisions or this CONTRACTOR NO. DATE p y p permit shall be F- deemed revoked. ADDRESS LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect.. �I icense Number Lic.Class (Contractor Date CHECK IF SUPERVISED GRADING ❑ SIGNATURE ❑ OF APPLICANT I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer TEL. acting in my professional capacity (Section 7051, Bug- ADDRESS- NO. s iness and Professions Code). SURETY$ BOND BOND NO. Lic.or Reg.No. Date SURETY COMPANY HOME OWNER-BUILDER DECLARATION DATE RECD FILED BY ISI 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): 'ages owner of the property, or my employees with THIS IS A LIMITED TIME PERMIT 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 17191 (Section 7044, Business and Professions Code). TIME LIMIT' I, as owner of the property, am exclusively contracting with licensed contractors to construct the project EXTENDED TO: BY: (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: e 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$ ;'� Permit Fee Lender's Name IIssuance 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 inspecti n purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of, ermittee Date