HomeMy Public PortalAbout6230-6236 ROSEMEAD BLVD_Grading__ \vORKERS'COMPEN9ATIONDECLARATION 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 certified copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. } 1} Company �•
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE
ADDRESS
❑ Certified co SITE
copy is filed with the count building g inspection A DRE S _ LOCALITY
department. --_ - -- -_--— —
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LOT NEAREST
DatesApplicant NUMBERS _ BLOCK CROSSSTREET
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT DISTRICT NO. MAP NO. STATE HWY. PROCESSED BY
COMPENSATION INSURANCE NUMBER
YE ❑ NO Ll �
(This section need not be completed if the work involved OWNER CUBIC YDS. 0
by the permit is for one hundred dollars ($100) or less.) MAIL
HANDLED:
ADDRESS
J
[ certify that in the performance of the work for which this TE L.
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permit is issued, I shall not employ any person in anv manner CITY - NO. USE ZONE SPECIAL
STATE CONDITIONS
io as to become subject to the Workers' Compensation Laws. ENGINEER REG. NO. }
-r•
DateY Applicant MAI
ADDRESSQ
NOTICE TO APPLICANT: if, after making this Certificate of CITY NEO ' 0
Exemption, you should become subject to the Workers' CL
7ompensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL BY
,vith comply with such provisions or this permit shall be CONTRACTOR NO. DATE
Seemed revoked.
ADDRESS
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION
hereby affirm that I am licensed under provisions of Chapter
(commencing with Section 7000)of Division 3 of the Busi-
less and Professions Code, and my license is in full force and
ffect. --
icense Number Lic.Class
CHECK IF SUPERVISED GRADING ❑
ontractor Date SIGNATURE
I am exempt from the licensing requirements as I am a OF APPLICANT TEL.'
licensed architect or a registered professional engineer ADDRESS NO.
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
FILED BY
hereby affirm that I am exempt from the Contractor's CASH RECD DATE
,icense Law for the following reason (Section 7031.5, Busi- DEPOSIT$ BY FILED
ess and Professions Code): THIS IS A LIMITED TIME PERMIT
] I, 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
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t,{ (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
,L,,ender's Name
Lender's Address Issuance Fee
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-mentioned vroperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date