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HomeMy Public PortalAbout5048 SERENO DR_Grading__ WORKERS'COMPENSATIONDECLARATION CE APPLICATION fOR- GRADING- PERMR ,CE 071REV 280) �. - 1 hereby affirm that I have a certificate of consent to self •I t insure, or a certificate of Workers'Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGE S BUILDING AND SAFETY Policy No Company ' ❑ Certified copy Is hereby furnished FOR APPLICANT TO FILL IN SIIDDRESS ❑•Certified copy is filed with the county budding inspection SITE DRESS Q LOCALITY department - Date Applicant LUMBERS BLOCK CROSSSTREET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS TRACTM O TE HWV P V COMPENSATION INSURANCE NUMBER �Cf STA 'i OWNER CUBIC YDS } (This section need not be completed If the work Involved AIL by the permM it Is for one hundred dollars ($IGO) or less) HANDLED odd '0 TEL `I certify that in the'performance of the work for which this 4INE .-.- © NO - SPECIAL" - - oQ permit n Issued, 1 shall not employ any person in any manner STATE CONDITIONS LZv 0 1 so as to become subject to the Workers Compensation Laws ....... REG NO Date Applicant NOTICE TO APPLICANT If after making this Certificate of NOL Z Exemption you should become subject to the Workers , Compensation provisions of the Labor Code, you must forth GRADING - - - TEL FINAL with comply with such provisions or this permit shall be CONTRACTOR NO DATE deemed revoked ADDRESS LICENSED CONTRACTORS DECLARATION PROPOSED VALIDATION I hereby affirm that I am licensed under provisions of Chapter JUSE OF GRADED SITEIS) J I 9 (commencing with Section 7000) of Division 3 of the Busi _ nese and Profusions Code and my licenseils in full force and effect r License Number Lic Clan- Contractor lass Contractor Date CHECK IFSUPERVISED GRADING ❑ • (((��1 - - OF APPLICANT ❑ 1 am exempt from the licensing requirements as I am a U licensed architect or a registered professional engineer TEL acting in my professional capacity ADDRESS NO - P Y (Section 7051, Bu! BOND S mese and Professions Code) _ BOND _ BONG NO- 1 Lic or Reg-No Date SURETY COMPANY y - • _ _ , HOME OWNER BUILDER DECLARATION DATE REC D - FILED - - BY 1 hereby affirm that I am exempt from the Contractor's CASH REC D DATE ' License Law for the following reason (Section 7031 5, Bust DEPOSITS BY FILED ' ness and Profusions Code) ITHIS IS A LIMITED TIME PERMIT ❑ I as owner of the property or my empployees 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 - ❑ 1, 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 - - - - 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is pp issued(Sec 3097 Civ C ) a P C Fee$ 1/4!� tY_(f) Permit Fee - Lender s Name , Lender's Address Issuance Fee certify that 1 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 gmldmg construction �f ' and hereby authorize representatives of this County to enter upon the above mentioned property for Inspection purposes SEEREVERSE FOR EXP ANATORY LANGUAGE 4 / . �Gs 00 <z Signature of Permittee Date WORKERS'Cat have aIONDECLARATION CES072T APPLICATION FOR GRADING PERMIT G� CE 807 T V.280) NJ I hereby affirm that I have a certificate of consent to self 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. Company C P� rc'�1L'k VRI>`WC ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE .�� i-�v; � ADDRESS ❑ Certified copy is filed with fire county building inspection SITERESS 5� L`,'Jv �i d C !T` LOCALITY (.r�7 department. h Date— Applicant LOT OUMBERS BLOCK V NEAREST - ,,,�� � f'1 F-4 VY CROSSSTREET CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT g DIS7,RICT MAP NO. STATE HWY. PROC BY } COMPENSATION INSURANCE NUM ER tl OWNER L ri, 4�!41 :j.I L I / Al CUBIC YDS. C7 (This section need not be completed if the work involved MAIL HANDLED: by the permit is for one hundred dollars ($100) or less.) D :E " =N r�fJ �'�N` _ �lL.r. - J 1 certify that in the performance of the work for which this CITY s'NIJ i. LI I>L 1% TEL. - ''l LL �✓ NO, ?�(}�. USE ZOtff SPECIAL permit is issued, 1 shall not employ any person in any manner STATE .JL, CONDITIONS } so as to become subject to the Workers' Compensation Laws. ENGINEER I. ( 12`-'-4 REG. NO. t.� � � Date Applicant /I✓(;. ADDRESS MAIL ;� , fi_ - _ i 1;; OV NOTICE TO APPLICANT: If, after making this Certificate of TEL. y;j ,. �,.( 2 Exemption, you should become subject to the Workers' CITY ♦� �� I r /'F NO. 2 Compensation provisions of the Labor Code, you must forth- GRADINCONTRACTORNOt. - DATE BVUJ with comply with such provisions or this permit shall be deemed revoked. ADDRESS LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION 1 hereby affirm that 1 am licensed under provisions of Chapter I J 1 T 9 (commencing with Section 7000)of Division 3 of the Busi- nessand Professions Code, and my license is in full force and It iJ r effect. License Number - Lic.Class a a e t g , Contractor' t4C1 I Jj 'lvrCDate CHECK IF SUPERVISED GRADING ❑ Q • 9 `SIGNATURE h OF APPLICANT L d - • ? t? r I am exempt from the licensing requirements as i am a _ 7E L. licensed architect or a registered professional engineer ADDRESS " .� (;.e f%!eft% IdN•/NO.�.;.. j' 7 n q acting in my .professional capacity (Section 7051, Bug- 07 4`6— 4 iness and Professions Code). SURETY $ BOND BOND NO. Lic,or Reg.No. Date SURETY COMPANY HOMEOWNER-BUILDER DECLARATION DATE BVC'D 1 hereby affirm that I am exempt from the Contractor's CASH RECD DATE License Law for the following reason,'(Section 7031.5, Busi- DEPOSIT$ BY FILED ness and Professions Code): THIS IS A LIMITED TIME PERMIT ❑ I, as owner of the property, or my empployees with 1 U A wages as their sole compensa ron, will do the work ALL WORK AUTHORIZED MUST BE COMPLETED BY _ and the structure is not roter�(dad or offered for sale tt e a 4 (Section 7044,Business and ProfMssions Code). TIME LIMIT: ❑ I, as owner of the property, a !! exclusively contracting �) e 40550 with licensed—cgptractors to construct the project - EXTENDED TO: BY: (Section 7044,Business andfessions Code). .. a 4 n S Jr ,J CONSTRUCTION LADING AGENCY EXTENDED TO: BY: I hereby of irm that then a construction lending agency for the pe ormance-. a work for which this permit is �i� 00,.. issued Sec. 3097,Civ.C.). P.C.Fee$ /` Permit Fee Lender s Name Lender's Address Issuance Fee . I certify that 1 have read this application and state that the Total Fee v above information is correct. 1 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE f Signature of Permittee Date