HomeMy Public PortalAbout5405 ROSEMEAD BLVD_Grading__f �
WORKERS'COMPENSATION DECLARATION 76A641 APPLICATION FOR GRADING PERMIT
--'
I hereby affirm that I have a certificate of consent to self CE 807 (REV. 2-80) e i
insure, or a certificate of Workers'Compensation Insurance,or
a certifiedeo reo �h (Sec. 380 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No^�— Company:.. �✓:.r*1 e��)ZssTt ds11 y.
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE
ADDRESS
® Ir
Certified copy is filed with the county buildi inspection SA TDRE S fil `''r f �- � LOCALITY
d t 111. y' /
Datr7� Applicant � ✓ Jib,c NOUMBERS n:.4 .L.,. BLOCK NEAREST
CROSS STREET
CER IFICATE OF EXEMPTION FROM WORKERS' TRACT DISTRICT NO. M/�P NQ. STATE HWY.YE ❑ O, PROCESSED BY
NUMBER y
COMPENSATION INSURANCE JJ
OWNER //V -2
' 'am CUBIC YDS. j CJ
I (This section need not be completed if the work involved MAILf-
HA N D L E D:
by the permit is for one hundred dollars ($100) or less.) ADDRESS
tsa
I
I certify that in the performance of the work for which this CITY °l:. /`et"ft �" } NO. 4' '� 'C' I
permit is issued, I shall not employ any person in any manner USE ZONE SPECIAL
so as to become subject to the Workers'Compensation Laws. ENG r �ry,STATE y f {' CONDITIONS
1 p � ! ^� REG.
Date Applicant MAIL E *)(-/rr /— 3 li:'i(G G' - <
Cc
NOTICE TO APPLICANT: If, after makingthis Certificate of f` i TEL. ry r / d C
Exemption, you should become subject to the Workers' CITY >(.' "Y — = NO. 7 / f�
Com ensation provisions of the Labor Code, you must forth- GRADINGS '% r TEL. { FINAL BY LU
p p L''� .i l 3' �� C f
with comply with such provisions or this permit shall be CONTRACTOR eNC L DATE
~
deemed revoked. ` ?f VL /
ADDRESS c4'
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000)of Division 3 of the Busi-
mess and Professions Code, and my license is in full force and
effect. ,e _
License Number �� 1� Lic.Class
7�+.j�}m �, r 6 r % CHECK IF SUPERVISED GRADING _ n
ontractor✓ Date ��r SIGNATURE
❑ f < J ri' (l''f%�l i `' �� Ir
I am exempt from the licensing requirements as I am a OF APPLICANT /
licensed architect or a registered professional engineer ADDRESS --> ? > -tiE NOLJ
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). SURETY $ BOND
BOND NO.
Lic,or Reg.No. Date SURETY
COMPANY
HOME OWNER-BUILDER DECLARATION DATE RECD r' t
FILED BY v\'Y.; A
I hereby affirm that I am exempt from the Contractor's CASH RECD DATE r ` i a .0 0 t
License Law for the following reason (Section 7031.5, Busi- DEPOSIT$ BY FILED
Hess and Professions Code): •
❑ I, as owner of the property, or my employees with THIS IS A LIMITED TIME PERMIT
wages as their sole compensation, will do the work ALL WORK AUTHORIZED MUST BE COMPLETED BY f
and the structure is not intended or offered for sale • li,a ;'
(Section 7044,Business and Professions Code). TIME LIMIT:
❑ I, as owner of the property, am exclusively contracting # 7,
with licensed contractors to construct the project EXTENDED TO: BY:
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency EXTENDED TO: BY:
for the performance of the work for which this permit is / r
issued (Sec. 3097,Civ.C.). P.C. Fee$ ! Permit Fee ) /
Lender's Name
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-mefj�ti(6ned property_ r inspection/jpur s
SEE REVERSE FOR EXPLANATORY LANGUAGE
'Sign ure of Pei"inittee Date
I