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Home My Public Portal About9312 OLIVE ST_Grading__ J WORKERS'COMPENSATION DECLARATION 76A641T N hereby,ctffiFm�4hd1 I have a certific9te ohonser t tose)f insure; CE 807(REV.z-eo)10/80 ,APPLICATION- FOR- GRADING PERMIT or a.certificafe of Workers'Compensation.-Insurance, or a cer- tified copy therebf(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. 'Company El • SITE Certified copy is hereby fu:enished. FOR APPLICANT TO FILL IN ADDRESS ,9cI _ ❑ SITEADDRESScopy is filed with the county building inspection ADDRESS . 1, LOCALITY department. LOT NEAREST Date Applicant NUMBERS BLOCK CROSS STREET 1 TRACT DISTRICT O. MAP NO. STATE HWY. ESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS.' NUMBER p YES❑ 'IVO ❑ � � COMPENSATION INSURANCE. -r� �QO I OWNER OLAV2 i��5, A• CUBIC YDS. (This section need not be completed'if the work involved by MAIL HANDLED: the permit Is for one hundred dollars($100)or less.) ADDRESS ub CH-a -tom TEL. Ct'U I certify that in the performance of the work for which this per- CI A) 6KRJA10NO. 6 USE ZONE SPECIAL mit is issued,I.shall not employ any person in any manner so as .6,�� STATE CONDITIONS to become subject to the Workers'Compe ion Laws.,. ENGINEER \ � REG. NO. Date pplicant au ADDRESS fo�: QX GTOAJ^q V TEL NOTICE TO APPLICANT:If,after making this.Certificate of Ex- CITY IVO.1� emption, you should become subject to the Workers'Compen- GRADING r� TEL. 11 FINAL BY J sation provisions of the Labor Code,you must forthwith comply CONTRACTOR. ,a NO..to U L_ DATE �/) with such provisions or this permit shall.be deemed revoked. "( LICENSED CONTRACTORS DECLARA'T'ION ADDRESS 0, (. OSe eA) Ta C- 1 hereby affirm that I.am licensed under provisions.of Chapter 9 PROPOSED USE OF GRADED SITES) VALIDATION (commencing with.Section 7000) of Division 3of the Business A� and Professions Code,and my license is in full force and effect. ti License'Number Lic.Class s ' Contractor Date CHECK IF SUPERVISED GRADING ❑ 1 am exempt from the licensing requirements as I am a SIGNATURE licensed architect .or a registered .professional engineer OF APPLICANT acting,in my professional,capacity(Section 7051, Business NO tl and Professions Code). ADDRESS �p�3. CINed @A NO.dl .�,0 SURETY$ 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 COMPANY 4 DATE REC Law for the following reason(Section 7031.5,Business and Pro- FILED BY.D ACCToA fessions Code): CASH RECD DATE nr� �s E] 1, as owner of the property, or my employees with wages DEPOSIT$ BY FILED 3303 264.00 as their sole compensation,-will do the work and the strut- THIS IS A LIMITED TIME PERMIT ITE ture is not intended or offered for sale (Section 7W41 MS Business,ond Professions Co.06). ALL WORK AUTHORIZED MUST BE COMPLETED BY TOTAL 264 o 00 ❑ I, as owner of the property, am .exclusively contracting TIME LIMIT' CHECK 264000 with licensed contractors to construct the project (Section 7044; Business and Professions Code). CHANGE .00 CONSTRUCTION LENDING AGENCY EXTENDED TO: 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. �a�—000i 10/273/951 3097, Civ. C..). 7d P.C. Fee$ . Permit Fee 2844 AMn 17 Lender's Name D Issuance Fee Lender's Address // 1 certify that I have read this application and state that the Total FeeA.&_ O.6 above information is correct. I.agree to comply with all County ordinances and State laws relating to building construction,and hereby a thor' epresentatives of this County to enter upon th above I ed property for in .ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .Signature of ermittee ®^ Date~ r