HomeMy Public PortalAbout5122 ROSEMEAD BLVD_Grading__ WORKERS'COMPENSATION DECLARATION CE 807 T APPLICATION FOR -GRADING " PERMIT
CE 807 (-REV. 2-80) - -
I hereby affirm that .I-!have a certificate-of,consent to self.
insure,'or a certificate of Workers'Compensatiori Insurance,or _
a certified copy,thereof(Sec, 3800,Lab_ C.) COUNTY OF LOS ANGLES ILOING.AND'SAFETY
Policy No: Company _
❑ Certified copy is hereby:.furnished..`, ^ FOR APPLICANT TO FILL IN
SITE
d _ ADDRESS
❑ Certified copy-is-filed with the county building.inspection SITE
ADD ESS �` -JizvX=NIV LOCALITY
department.
LOTT
e EAREST
Date -'' Applicant NUMBERS / u?�L _" &0. BLOCK CROSS STREET` y
CERTIFICATE OF EXEMPTION_FROM WORKERS";.' TRACT ' ` " DIS�Tly M P D." STATE HWY.. PROCESSED BY.
COMPENSATION INSURANCE r NUMBER ` (//
r
01NNER
(This-section-':,need not be.completed.if the work involved 0—
MAIL - '' HANoLE�S '
. � ^.•.. _ - z. .. �� .� •_ YES NO L� } �'
a
by the permit is for _one,hundred dollars ($100) or Jess.) ADD � Z`� U /�/ AJAK7 �"
" . .. :, , /;lacy •.
I certify that in the pe`rforniance of.the wo r which',this CLTY- �L'" - - NOL ZZZ'Z(?Q
permit is issued, I shall no p oy .-" perso in any manner STATE U _ CONDISPECITIONS
IONS 0
)� >`7 ZO
so as'to become subject t the_Wo=ker C p cation La ENGINEER (l�Al 5..• L REG, NO. -
MAIL
Date Applicant ADDRE o
NOTICE-TO APPLICANT-.If, afte akirig•this Certificate of r' - EL: y 4 z `
Exemption you 'should become bject to the- Workers' .
CITY /T�!� LLC. NO G.�Z
Compensation'provisions of the,Labor'Code, you must"forth- GRADING -- TEL: - FINAL - BY
with comply. with ,such provisions or`this permit- shalh.be CONTRACTOR NO.-. ' DATE'.
deemed revoked. - - - {
ADDRESS'-
LICENSED CONT�ACTORS:DECLP:RATION PROPOSED USE OF GRADED-SITES) VALIDATION
r
I hereby affirm that I am licensed under provisions of:Chapter . � �r d � .�y
9 (commericmg with Section 7000) of Division 3--of the Busi-
ness and Professions Code, and my, license,is in full'force and '
effect.
License Number, Lic.Class = r«
i -, ',.•Y.a: CHECK.IF SUPERVISED RADING ❑ -
onfractor Date SIGNATURE f
❑ OF.APP_LICANT "
I am exempt from.Ole licensing requirements as I'`am a TEL: r3:.
licensed architect or a registered professional engineer P:DDRESS -�:` / er� O..-L �: GtJ• -
acting in 'my professional capacity (Section 7,651,;,Bus
' iiiess and Professions Code). SURETY $" S4 lle35 BOND
BOND .. . ,..: NO
Lic.or.Reg.No.' Date " ' SURETY
CONIPANy
HOME OWNER-BUILDER DECLARATION DATE RECD
FILED' „. < BY
I `hereb'y affirm that I am exempt.from the Contractor's CASH REC'D:.+ DATE
0 0
License Law for the following.reason"
(Section 7031,5, Busi-' . • DEPOSIT.$ BY` FILED".
ness and Professions Code): ,20,21 7,0 0
I, as owner of the "property, or my emplby;ees with
THIS IS A.LIMITED TIME PERMIT
wages'as their' sole"compensation, will do the work ' C - - ° �L 1;7,
and the structure is not intended or offered for sale ALL WORK AUTHORIZED MUST BE.COMPLETED BY
(Section 7644, Business and Professions;Code). _
TIME LIMIT _
1, as owner of the property, am exclusively coniracting
03 -81
with licensed .contractors to construct the project _.
(Section 7044, Business and Professions Code), EXTENDED TO
CONSTRUCTION LENDING AGENCY EXTENDED TO:
I. hereby affirm .that there is a construction:lending agency.. -
for the performance of the.work for which this.perrriit is 1
issued(Sec. 3092,.Civ.C.). P.C..Fee.$.'- - Permit Fee.:
Lender's Name
Lender's Address Issuance;Fee= .. _.
I certify that I ha ead, this application and state that the Total Fee
above information s correct. I agree to comply with all:County
o,�rd Sta laws relatingto building construction,uthoriz representative of this County to entere- nti n ection purposes. A/,? SEE REV RSE, OR EXPLANATORY'LANGUAGE
Signatur f Permittee Date ;