HomeMy Public PortalAbout9925 LOWER AZUSA RD_Grading__ WORKERS'COMPENSATION DECLARATION 76A641T
hereby affirm that I hoveb certificate of coAsent to self insure, CE 807(REV. 2-80)10,80 APPLICATION FOR GRADING PERMIT
or a certificate of Workers'Compensation Insurance, or a cer-
tified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Cbrtified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE
as-
SITEC
9112010
ElCertified copy is filed with the county building inspection ADDRESS a LOCALITY V
apartment. LOT Q' NEAREST0:
Date Applicant NUMBERS V BLOCK CROSS STREET C
CT
NUMBER oaTU NO STATE HWY. V
CERTIFICATE OF EXEMPTION FROM WORKERS' YES 0 W
COMPENSATION INSURANCE OWNER /� CUBIC YDS. A
(This section need not be completed if the work involved by MAIL ANDLED- 3
?
the permit is for one hundred dollars($100)or less.) ADDRESS 10 G�
TEL.
I certify that in the performance of the work for which this per- CITY �1 USE SPECIAL
mit is issued,I shall not employ any person In any manner so asSTATE CONDITIONS
to become subject to the Workers'Compensation Laws. ENGINEER '/ REG. NO.
MAIL sa7cs—
Date Applicant ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITYTEL'
emption, you should become subject to the Workers'Compen- ' NO���
lotion provisions of the Labor Code, you must forthwith comply GRADING TEL. FINAL , BY
with such provisions or this permit shall be deemed revoked. CONTRACTOR NO. DATE
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITES) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license Is in full force and effect.
1
License Number Lic.Class
Contractor Date
CHECK IF SUPERVISED G ING z 0 8 Q 2 A
❑ I am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT .18096pr
acting in my professional capacity (Section 7051, Business ADDRESS NL. 8 #- 28500
8
and Professions Code). SURETY$ • - 285005
Lic.or Reg.No. Date BOND NO.
0 9 3 0+8 8
HOME OWNER-BUILDER DECLARATION SURA
I hereby affirm that I am exempt from the Contractor's License COMPANY
Law for the following reason(Section 7031.5, Business and Pro- DATE FILED BY
fessions Code): +=�
CASH RE RECD DATE A:CT.� '
F1I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED
as their sole compensation, will do the work and the struc- THIS IS A LIMITED TIME PERMIT -3107 71.25
tura is not intended or offered for sole (Section 7044, r�pt_
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETES
D BY 1 ITEMS
Gt
❑ 1, as owner of the property, am exclusively contracting TOTAL '�1
with licensed contractors to construct the project (Section TIME LIMIT:
. 25
7044, Business and Professions Code). CHE``K 71 �r
CONSTRUCTION LENDING AGENCY EXTENDED 70: BY: '� �"
I hereby affirm that there is a construction lending agency for
EXTENDED TO: BY:
the performance of the work for which this permit is issued(Sec. .p
3097, Civ. C.). P.C. Fee$
ermi OMD—(Ml 3/12/9tl
Lender'asName pp'�
Lender's Address ssuance Fee V 94514 1 AM11:05
I certify.that I have read this application and state that the Total Fe f/
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,and
hereby authorize repre ntatives of this County to enter upon W
the abov a boned p, perty for inspection purposes. SEE REVERSE FORE LVATORYIRGUAGf
7. O O O
�Signatur Permittee 60 Date 1 ;j 8 so