HomeMy Public PortalAbout9713 LOWER AZUSA RD_Grading__ WORKERS'COMPENSATION DECLARATION 76A641T
CE 807 (REV 2 Bol APPLICATION FOR GRADING PIRRIIT
I hereby affirm that I have a certificate of consent to self
insure,or a certificate of Workers'Compensation InsMance,or j
a certified cop there
'04V 380o C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NOO Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN SITE
ADDRESS
Certified copy is filed with the county building inspection SITE
de art Int �Jl LOCALITY ! j
Dat e%�l Applicant T NUMBERS BLOCK NEAREST
T
CERTIFICATE OF EXEMPTION FROM WORKERS' kAD
Gl Taj
COMPENSATION INSURANCE
UMBER rJ / DISTRICT MAP NO STATE HWY RMI BY
(This section need not be completed if the work involved CUBIC YDS a•
by the permit is for one hundred dollars ($100) or less) ADDRESS 7S HANDLED O
I certify that in the performance of the work for which this 7 �� U
NOTE L S7S'•�Sv� rr
permit is issued, I shall not employ any person in any manner STATE ' �'� USE ZONE CONI)IATIONS
so as to become subject to the Workers'Compensation Laws R REG NO l—
U
Date Applicant � s W
a
NOTICE TO APPLICANT If, after making this Certificate of TEL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- TEL FINAL BY
with comply with such provisions of this permit shall beCONTO DATE
deemed revoked
LICENSED CONTRACTORS DECLARATION ROPOSED USE OF GRADED SITE(S) VALID A
iI hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000)of Division 3 of the Busi- # • • • • 8
ness and Professions Code, and my license is in full force and
effect 1 * 667.50
;License Number Ltc ClassL
Contractor��✓4t� Date y�'6 CHECK IF SUPERVISED GRADING ❑ • * 66Z505
SIGNATURE
131 am exempt from the licensing requirements as I am a OF APPLICANT Q 1. 1 7—8 6
licensed architect or a registered professional engineer ADDRESS T
acting in my professional capacity (Section 7051, Bus-
mess and Professions Code) SURETY$ BOND 1
BOND NO
Lic or Reg No Date SURETY
250 ' A
HOME OWNER-BUILDER DECLARATION FILED BVC,D # �
License LawI hereby fifor the that
followingexempt
reason (Section 7031 S, Busi- DEPOSIT$ BYC D FILED • 1.50
ness and Professions Code)
❑ 1, as owner of the property, or my employees with THIS IS A LIMITED TIME PERMIT 1 • — 1,50
wages as their sole compensation, will E 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)
0 i, as owner of the property, am exclusively contracting TIME LIMIT•
;15052A
with licensed contractors to construct the project EXTENDED TO BY
(Section 7044,Business and Professions Code) # • • • • •�
CONSTRUCTION LENDING AGENCY EXTENDED TO BY
I hereby affirm that there is a construction lending agency 1 • a 2 a 0 0
for the performance of the work for which this permit is • * 82a0051
issued SSec 3097,Civ C) �s/tel PC Fee$ Permit Fee S
Lender s Name 'f���JJ _ /� O f 04
g
Lender's Address 50
!/� Issuance Fee " '' 9
) # • • • • 18
1 certify that 1 have read this application and state that the Total Fee (/
above information is correct 1 agree to comply with all County 1 • 5 Q 0 0
ordinances and�Y"
relating to building construction,
and hereby autesentatives of this County to enter • • 5 Q 0 0 c=i
up h ve rty for inspection purposes F SEE REVERSE FOR EXPLANATORY LANGUAGE