HomeMy Public PortalAbout5242 SERENO DR_Grading__ I ,
to WORKERS'COSIPFNSA I ION DFCI ANA I ION 7&M41 T APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self insure CE 907(REV Z 90)10/80
or a certificate of Worker/Compensation Insurance or a car j
COV cothereof(Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING, AND SAFETY r
Policy No Company
SITE
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS SR ' S'2 , C
❑ Certified copy is filed with the county building inspection ASS LOCALITY s tl
department LOT NEAREST C
Date Applicant NUMBERS &OCK TRACT DIS CROSS STREET FC
Tni �'�J TE IIVly t
CERTIFICATE OF EXEMPTION FROM WORKERS' NUMBER ' V VES O NO 0
COMPENSATION INSURANCE
' OWNER CUBIC YDS Z
(This section need net be corepksted N the work Invoked by MAIL N/iNOIED
the perntD is for one hundred dollars(111100)or less ) ADDRESS
I cenify that in the performance of the work far which this per Cm NO w ` USF _ SPECIAL ,
mit is issued I shall not employ any person in any manner so as STALE CCN4=M
to become subject to the Workers Compensohon lows ENGINEER REG NO
MALI
Date Applicant I ADDRESS 2920 go' C&LOCA011P
TEL
NOTICE TO APPLICANT If otter making this Certificate of Ex- CITY No S
ampticn, you should become subject to the Worker/Compton GRADING - TEL FINAL B
eaten provisions of the Labor Code, you must forthwith comply CONTRACTOR NO DATE
with such provisions or this permit shall be deemed revoked
LICENSED CONTRACTORS DFCI ARA I ION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALID ON
(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
6,$10�
Contractor Dote 1V sg
CHECK IF SUPERVISED GRADING A�4T a
❑ I am exempt from the licensing requirements as I am a h
licensed architect or a registered professional engineer I M7 667.50
acting in my professional capacity (Section 7051 Business ADDRESS TELtig
• and Professions Code) NO IdIl"Idsig 1 ITEMS ,
MRErY BOND
Lic or Reg No Date BOND f
NO TOTAL 667 .50
HOME OWNER BUILDER DECLARATION SURETY
COMPANY �Ltcrs 66'7.5Q
1 hereby affirm that I am exempt from the Contractors License DATE REC D 4f7G
Law for the following reason(Section 7031 5 Business and Pro- FILED BY - CHANGE •00
fesslons Code) •
64511 RECD GATE i
❑ 1 in owner of the property, or my employees with wages DEPOSIT f By FILED
as their sole compensation will do the work and the smut THIS IS A LIMED ITTIME PERMIT I yy 001 1/ 5/84
ture a not intended or offered for sale (Section 7044 ws�
Business and Professions Code) I ALL WORK AUTHORIZED MUST BE COMPLETED BY �' +S OL 1 AM 9•33
❑ 1 as owner of the property am exclusively contracting TIME LIMIT.
with licensed contractors, to construct the project (Section P -
70M, Business and Professions Code) I ,
CONSTRUCTION LENDING AGFNCY r EXTENDED TO BY
I hereby 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 f0626-0 Permit Fee
Lender's Name
Issuance Fee
Lender s Address
I certify that I have read this application and state that the Total Fee
above information is correct I ogre&to comply with all County
ordinances and Slate 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 ,
Signature of Permittee Dote