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HomeMy Public PortalAbout6004 ROSEMEAD BLVD_Grading__ 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) insure, or a certificate of Workers'Compensation Insurance,or a certif�d c, y--thereo S 3 0,Lab. ? �"�' � C'��tv COCOU�TY OF LO ANGELES ��jN BUILDING AND SAFETY ow Policy'No. 3` comlflnY Certified copy is hereby furnished. FOR APPLICANT--TdFILL IN SITE ADDRESS . ISITE "Certified copy is filed with the county building ectionRE ` LOCALITY de t it. ADDLOT NEAREST Dateiz_ App'ca NUMBERS BLOCK ROS TREET CERTIFICATE OF EXEMPTION OM WORKERS' TRACT 78 J?O DISTRICT N0. MAP NO. STATE HWY. PRO SSED•BY COMPENSATION INSURANCE NUMBER O • ' YE OWNER N011Qf.l- :%Ly_.n"r 5©, CUBIC YDS. } This section need not be completed if the work involved MAIL e� [� HANDLED: �- oy the permit is for one hundred dollars ($100) or less.) ADDRESS /Z7-7^ V/• / 7�' O certify that in the t f/ TEL. performance of the work for which this CITY 4� NO. USE ZONE SPECIAL � permit is issued, I shall not employ any person in any manner STATE CONDITIONS O o as to become subject to the Workers' Compensation Laws. ENGINEER tr- REG.NO.�GE � 7 �^ U )ate Applicant 97 AD ORMAIL E 3 ZO G • J— I'i) /C 2 dOTICE TO APPLICANT: If, after making this Certificate of NECL. Z :xemption, you should become subject to the Workers' CITY & Q G N . 9' 32 'ompensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL By vith comply with such p CONTRACTOR N0. �- C DATE p y provisions or this permit shall be ��/ .•. ,.�' leemed revoked. ADDRESS 12-7-7 LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRAD D SITE(S) VALIDATION hereby affirm that I am licensed under provisions of Chapter x�o (commencing with Section 7000)of Division 3 of the Busiit Sin 144 - ess and Professions Code, and my license is in full force and Ffect. icense Numb �er 3445VoZ.Lic.Class ontractor .t� •��� 27. Date 9�4IS D CHECK IF SUPE G A I yr SIGNATU I am exempt from the licensing requirements as I am a OF APPLI NT licensed architect or a registered professional engineer122-7W. TE NO.. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). SURETY$ BON D BOND JIT NO. Ac.or Reg.No. Date SURETY COMPANY HOME OWNER-BUILDER DECLARATION DATE RECD FILED BY hereby affirm that I am exempt from the Contractor's CASH REC'D DATE icense Law for the following reason (Section 7031.5, Busi- DEPOSIT$ BY FILED ess and Professions Code): THIS IS A LIMITED TIME PERMIT ] 1, as owner of the property, or my employees with wages as their sole compensation, will do the work ALL WORK AUTHORIZED MUST BE COMPLETED BY and the structure is not intended or offered for sale _ (Section 7044,Business and Professions Code). TIME LIMIT' I, as owner of the property, am exclusively contracting with licensed contractors to construct the project EXTENDED TO: BY: (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY EXTENDED TO: BY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). P.C. Fee$ Permit Fee Lender's Name Lender's Address Issuance Fee J I certify that I have read this application and state that the Total Fee / above informati Is:Tcl-I agree to comply with all County ordin es at ate law r g to building construction, here ze r p fives of this C unty o enterCfpon abontio perty for i c '7n pu oses. SEI REVERSE POI2 EXPLANATORY LANGUAGE f- ignature o ermittee Date