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Home My Public Portal About5533 ROSEMEAD BLVD_Grading__ 76A..IV-G0.379IE_75 r APPLICATION FOR GRADING PERMIT BUILDING SAFETY DIVISION FOR APPLICANT TO FILL IN SITE SITE ALDDRESS G��{./�l/ /JCr LOCALITY NUMBERS BLOCK NEAREST C O35 ST NUMBER DI3 iR ICT NOo MAP NO STA E HWY ES{E Y �QQ YES NO OWNER (,� j �� U20NE 9P ECIAL M AIL _Z CON OITION9�� 7� C ADDRE99 CITYH NOL ]TATE ENOINEE �Aw REG NO 55 EE MAIL, }J`yL�)� BONDTY S NONO ADDRE99 D aZ 55 A W 36 TEL GORET CITY / NOMPAN GRADING TOL DATE RECD CTOR CONTRAN FILED By ^^ EE iy1 ADDRESS OEP091T BYC,D FILED O PROPOSED USE ��jjO�SF GRADED SITE(S) THIS IS A LIMITED TIME PERMIT SKI {,oE? � lirwALL WORK AUTHORIZED MUST BE COMPLETED BY TIME LIMIT. Tom" z EXTENDED TO BY EXTENDED TO BY CHECK IF SUPERVISED GRADING INITIAL DATE INSPECTOR'S SIGNATURE ORA u GRO MCP SIR PL ICE ANT COM nACT10N REnORT RECD A � TEL ��'�// SUP END R'3 I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS CCRT RECD APPLICATION AND STATE THAT THE ABOVE IS ROUGH GRADING CORRECT AHD AGREE TO COMPLY WITH ALL COUNTY APPROVAL / ORDINANCES AND STATE LAWS RE GULATINO EXCA- PLANTING AND VATING AND GRADING IRRIGATION SIGNATURE OP SUP ENOR'3FINAL CERT PE RMIT TEE FINAL APPROVAL AGENT FOR SURETY FOND RELEASED ADDRESS ' PC FEeS S PeTTnIt FEE CUBICYD] HANDLED '//7�'` Itslmnca Fee d&14O TGtel Fee ZS PLAN CHECK VALIDATION M 0 CASH PERMIT VALIDATION CK M 0 CASK 804'�fEB 2318 1) 255.00 889"`fl us 4 D 255UC) ^ WORKERS COMPFNSA I ION DFCT ARA I ION 76AUIT herebyaffum that I have a certificate of consent to self insure CE 907(REV 2180) 10,80 APPLICATION FOR GRADING PERMIT or a certi4icote of Workers Compensation Insurance or a car tified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Is hereby furnished FOR APPLICANT TO FILL IN SITE > ❑ Certified copy Y ,rte ADDRESS ❑ Certified copy a filed with the county building inspection gWRE55 3 QSE E' LOCALITY • Q deportment LOT V NEAREST C Dare NUMBERS Applicant BLOCK CROSS STREET Q TRACT CERTIFICATF OF tXFMPTION FROM WORKERS NUMBER oisrnlcr Na MAP NO STATE HWY Y COMPENSATION INSURANCE y D YES O NO O OWNER CUBIC YDS (This secflat need not be completed If the work Involved by MAILthe permne HANDLED r� Z the Is for ohundred dollars(SI00)or less) ADDRESS -5 TEL I certify that In the performance of the work for which this per Cin NO USE ZONE SPECIAL mit Is Issued I shall not employ any person In any manner so as STATE CONDITIONS to become subject to the Workers Compensation Lows ENGINEER EG NO MAIL Date Applicant ADDRESS/C670 NOTICE TO APPLICANT If, after making this Certificate of Ex CI NLp d s emption you should become subject to the Workers'Comport GRADINGi74(-,S TEL FINAL BV sation provisions of the Labor Code, you must forthwith comply CONTRACTOR NO DATE with such provisions or this permit shall be deemed revoked ADDRESSLICET LICENSED CONRACTORS DFCI ARA I ION ' I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE($) VALIDATION (commencing with Section 7000) of Division 3 of the Business SO.if �.LtS .J� Q and Professions Code and my license Is In full force and effect - Poo License Number Lrt Class Contractor Date CHECK IF SUPERVISED GRAD ❑ I am exempt from the licensing requirements as I am a SIGNATU licensed architect or a registered professional engineer OF APPLICANT acting In my professional capacity (Section 7051, Business at I and Professions Code) S7f of 23 SURETY S BOND Lic or Reg No Dole'- BOND NO HOME OWNFR-BUIL'DFR DECLARATION SURETY I hereby affirm that I am exempt from the Contractor's License COMPANY Low for the following reason(Section 7031 5 Business and Pro DATE REC D - fetsions Code) • FILED BY CASH REC D DATE ACCT.i ❑ I as owner of the property or my employees with wages DEPOSIT f BY FILED -- -I as their sale compensation, will do the work and the strut lure 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 L ITEM ❑ 1 as owner of the property am exclusively comrocting I OTAL 332 - 70 with licensed contractor to construct the project (Section TIME LIMIT: 7 70", Business and Professions Code) CHECK .z`.4 BY CONSTRUCTION LENDING AGENCY EXTENDED TO - '_HFIhhTE ._1_ I hate 6y 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 ) PC Fee S Permit Fee („s30 (IZ 6I 7/1?,, Lender's NomeCr , Issuance Fee �j, � 1 AM ��=h Lender i Address 9 I certify that I have read this application and state that the Total Fee L63c7•70 above Information is correct I agree to comply with ail County ordinances and State jaws relating to budding construction and he asst orize represenfa�es of County to enter upon oo I bendo a see far non tyr s SLE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pefmittee Date