HomeMy Public PortalAbout6019 PRIMROSE AVE_Grading__ 'WPRKERS'COMPFJVSA7'ION'.6FICI.A1fA'1'ION 7OA641T APPLICATION FOR GRADING PERMIT
I hereby, �•that_I hc}.ve a certificate of consent to self insure, CE.807(REV.2,80)10/80 �
or a certifica of Wrckers.'Compensation Insurance, or a cer-
fi f ig d copy:fhere f. ec..3800; Lab.C.)-- COUNTY OF LOS ANGELES" BUILDING AND SAFETY
Policy No. '`"�� Company -2
; ti.� SITE ,
EJ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESSSITE
ElCertified copy is filed with the county building inspection ADDRESS f + I�/iN�' (��c C LOCALITY
depa tme t. LOT t
ff NEAREST I
f�[ 31 �7YA li ��` ti'`G"�c'�-- NUMBERS BLOCK
Date pp'cant� ,. CROSS STREETTRACT 1
CERTIFICATE OF EXEMPTION FROM WORMRS' NUMBER oisTRia n1o. MAP NO. STATE HWY. ESSED BY
:0MAP
YES❑ NO
COMPENSATION INSURANCE. I
OWNER I L�o Y�c ,�. CUBIC'YDS, t
This section need not be completed if the work involved•b MAIL J HANDLED:
the permit is for one hundred dollars.(5100)or less.) y ADDRESS C' >` �U�f 1.;51—
TEL. d �
I certify that in the performance of the work for which.this per- CITY l:4 Pit i•tNG. _ NO. 6 02 � USE ZONE SPECIAL
mit is issued,I shall not employ any person in any manner so as STATE ,, CONDITIONS �a0.f/,�(S
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 Q�' FINAL BY
sotion.provisions of the Labor Code,you must forthwith-comply CONTRACTOR g '
with such provisions or this permit shall be deemed revoked. m.t^ NO.: //. DATE
LICENSED CONTRACTORS.DECLARATION
ADDRESS / / >1 �.e ZFil� ° ` tE
I hereby affirm that I.am I'icensed under provisions of Chapter 9 PROPOSED USE OF WADED 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 Num berl1 Q Lic.Class C
Contractor C,` 4'}r'•UA Date ►�i`'�i i`f
ECHECK IF SUPER SED.IGRA ING ❑ ,
❑ I am exempt from the licensing requirements'as I am a NATURE
licensed architect or a registered .professional engineer OF APPLICANT
acting•in my professional capacity(Section 7051,.-Business ? 1� TEL. _ (JJ2
and Professions Code). ADDRESS ,I )J% C ., NO. rf '
SURETY$ BOND
L'ic.or Reg.No. Date BOND NO.
HOME OWNER-BUILDER DECLARATION SURETY
I hereby affirm. that I am exempt from the Contractor's License _.COMPANY
icenseCOMPANY
Law for the following reason(Section 7031.5,Business and Pro DATE RECD !r
fessions Code): FILED BY 1'T tv
CASH RECD DATE
❑ I, as owner of the property, or my employees with.wages DEPOSIT$ BY FILED 33103 ��f'i 13
as their sole.compensation,will do the work and the.struc- ''
tu.re is not ,intended or offered for sale (Section 7044, THIS IS A LIMITED TIME PERMIT
Business and Professions Code). ALL WORK AUTHORIZED MUST,BE COMPLETED BY I ITEM
❑ I, as owner of the property, am exclusively contracting T O 1 nL 332 a 0
with licensed contractors to construct the project (Section TIME LIMIT: '• *"� fir' l1
7044, Business:and Professions Code). �. (,� `�`"
CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: CHANGE JD)
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.
3097,Civ. C.
P.C. Fee$ Permit Fee ��, t010—,ti11:9i 1'Y31/794
'Lender's Names <--^
Issuance Fee T 747 1 AM10
Lender's Address
I certify that I have read this application and state that the Total Fee3 �
above information is correct. I agree to comply with all County
ordinances and Ste laws re a ing to building construction,and
hereby 06 00 represe dives of this County to enter upon '
the abov .m do .d pr rt
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
GYM i!'�+•v" "
Signa. ye.of Permf a itDate !