HomeMy Public PortalAbout6142 ROSEMEAD BLVD_Grading__ WORKERS' have a NSAIION DECLARATION 76A641 APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80) 10180
or a certificate of Workers'Compensation Insurance, or a cer-
tified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
SITE C
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
SITE
❑ Certified copy is filed with the county building inspection ADDRESS LOCALITY
department. LOT
Date Applicant NUMBERS BLOCK NEAREST
CROSS STREET
TRACT DISTRICT NO. MAP NO. STATE HWY. PROCESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER
COMPENSATION INSURANCE YES❑ NO ❑ e
OWNER OBIC YDS. Q
tThis section need not be completed if the work involved b MAIL HANDLED: C
he permit is for one hundred dollars ($100)or less.) Y ADDRESS a C
TEL. 9
I certify that in the performance of the work for which this per- CITY NO. USE ZONE SPECIAL F
mit is issued, I shall not employ any person in any manner so as STATE CONDITIONS
to become subject to the Workers'Compensation Laws. ENGINEER REG. NO.
MAIL
Date Applicant ADDRESS
NOTICE TO APPLICANT:If, after making this Certificate of Ex- CITY NO.
emption, you should become subject to the Workers'Compen- GRADING TEL. FINAL BY
sation provisions of the Labor Code, you must forthwith comply CONTRACTOR NO. DATE
with such provisions or this permit shall be deemed revoked.
ADDRESS
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITES) VALIDATION
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor Date ❑
CHECK IF SUPERVISED GRADING
❑ 1 am exempt from the licensing requirements as I am a SIGNATURE
licensed architect or a registered professional engineer OF APPLICANT
acting in my professional capacity (Section 7051, Business ADDRESS TEL
and Professions Code). NO.
SURETY$ BOND
Lic.or Reg.No. Date BOND NO.
HOME OWNER-BUILDER DECLARATION SURETY
I hereby affirm that I am exempt from the Contractor's License COMPANY
Law for the following reason (Section 7031.5, Business and Pro- DATE RECD
FILED BY
fessions Code): CASH REC'D DATE
❑ I, as owner of the property, or my employees with wages DEPOSIT$ BY FILED 4 t
as their sole compensation, will do the work and the struc-
ture is not intended or offered for sale (section 7044,
Business and Professions Code). ALL WORK AUTHORIZED MUST BE COMPLETED BY \� /
❑ I, as owner of the property, am exclusively contracting /� V
with licensed contractors to construct the project (Section TIME LIMIT:
7044, Business and Professions Code), I I`
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. EXTENDED TO: BY: t
3097, Civ. C.). — I111UUU)f If I /�/
P.C. Fee $ Permit Fee , ,r x
Lender's Name
Issuance Fee
Lender's Address
I certifythat I have read this application and state that the
PP Total Fee r
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,and 1"
hereby authorize representatives of this County to enter upon l !'
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPI.ANA7'ORY LANGUAGE
Signature of Permittee Date