HomeMy Public PortalAbout6211 MUSCATEL AVE_Grading__ WORKFRS'CPNIPF.NSATION DFCLARATION 76A6417 APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE 807-(REV. 2-60)10/80
or a cer-tifieat`of.Workers'Compensation Insurance, or a cer-
tified -
copy thereof (Sec. 3800, Lab. C.) COUNTY OF'LOS ANGELES BUILDING AND SAFETY
Policy Ni. Company SITE
y�
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESSTE
❑ Certified copy is filed with the county building inspection A DRESSi
7I ��II�L��tst.-�_ ��� LOCALITY _
department. LOT
Date Applicant NUMBERS BLOCK NEAREST
CROSS STREET 1
CERTIFICATE OF EXEMPTION FROM WORKERS, TRACT DISTRI r D. MAP NO. STATE HWY. SSED BY I
COMPENSATION INSURANCE NUMBER -Y ' ? YES❑ NO O ,y'
OWNER !�l'�-i'1 i , 1 CUBt
(This section need not be completed If the work Involved by MAILADDRESS / 7 3-f—
HANDLED:
' �Y.?( 1
the permit is for one hundred dollars($100)or less.)
. � TEL. 7 ,l
I certify that in the performance of the work for which this per- CITY >;yu 7I G `- NO. —/ yr USE ZONE SPECIAL
mit is issued, I shall not employ any person in any manner so as - STAT CONDITIONS
to become subject to the Workers'Compensation Laws. ENGINEER REG.NO.
MAIL
Date Applicant ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITY NO.
emption, you should become subject to the Workers'Compen- GRADING TEL. FINAL BY
sation provisions of the Labor Code,you must forthwith comply CONTRACTOR NO. DATE
with such provisions or this permit shall be deemed revoked. �Z
ADDRESS
LICENSED CONTRACTORS DFCLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 ROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business "
and Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor Date
CHECK IF SUPERVISED GRADING
❑ I am exempt from the licensing requirements as I am a SIGNATURE -
C
licensed architect or a registered professional engineer OFAPPLICANT 'C'-
acting in my professional capacity(Section 7051, Business ADDRESS TEL.
and Professions Code). NO.
SURETY$ BOND 1�
Lic.or Reg.No. Date BOND NO.
HOME OWNER-BUILDER DECLARATION SURETY ACCT.
OM
I hereby affirm that 1 am exempt from the Contractor's License CPANY
r
Law for the following reason(Section 7031.5,Business and Pro- DATE RECD .'�3a� 186°4.}
FILED
fessions Code): CASH RCT DATE 1 ITEMS
❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED t!=
as their sole compensation,will do the work and the struc- THIS IS A LIMITED TIME PERMIT TOTAL 186 a+''�=s
ture is not intended or offered for sale (Section 7044, CHECK 186°41
k1ith
usiness and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY
as owner of the property., am exclusively contracting
CHANGE .00 licensed contractors to construct the project (Section TIME LIMIT:
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: 0000-00Q1 2/21/96
I hereby affirm that there is a construction lending agency forEXTENDED TO: BY: 4943 n 7 1 AM 9°°5•J c
the performance of the work for which this permit is issued(Sec.
3097, Civ. C.). P.C. Fee$ Permit Fee s .
Lender's Name , 30
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-menti ed property for Inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE.
Signature of Permittee Dafe