HomeMy Public PortalAbout5540-5542-5544 SULTANA AVE_Grading__ WORKERS COAIPENSA I ION DFCI ARA 110% 76A641I
I hereby affirm that I have o Certificate of consent to self insure CE 907 Inv Z 80)10,80 APPLICATION FOR GRADING PERMIT
or a certificate of Workers Compensation Insurance or a cer
tified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES WILDING AND SAFETY
Policy No Company
❑ Cenifted copy is hereby furnished FOR APPLICANT TO FILL IN SITE r 9 J�
—T- O
❑ Certified copy n filed with the county building inspection ADDDRE55 LOCALITY / i(,(. / f1
deportment LOT _ LY
NEAREST
Date Applicant
NUMBERS BLS CROSS STREET 9L
` NUMBER arTR�T Np NO STATE HLVY
CERTIFICATE OF EATION IONFROMWORKFRS Jr / )w �O NOO cc
• COAIPFNSATION INSURANCE - L+
OWNER CUBIC YDS _
(This section need not be completed H the work Involved by MAILI RL HANDLED
thepermit N for om hundred dollen(1100)or leas) ADDRESS
I cenify that in the performonce of the work for which this per Cm NO USE ZONE SPECIAL -
mit is issued I shall not employ any person in any manner so as ENGINEER REG N, ✓ COhDIT10N3
to become subject to the Workers Compensation Lows '
MAIL
Dote 6! Apphcant�,T-,: ILZ JfZ/A ADDRESS ^
NOTICE TO APPLICANT If, after making this Certificate of Ex- Cin, TEL
`
emption, you should become subject to the Worken'Compen GRADING -- TEL FINAL BY
satwn provisions of the Labor Code you must forthwith comply CONTRACTOR ^`!/. J/_- Y I`NOt DATE
with such provisions or this permit shall be deemed revoked
LICENSED CONTRACTORS DFCI ARA I ION ' ADDRESS F' %�' '" ' t"'•}T •� ";t _ l., d. +'-1
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business X11,.-
and Professions Code and my license is in full force and effect llq)•nL 7�f a�t
t
License Number� f L L¢ Class t t 4
Contractor ��Date r 4 ` 1 ❑ ++f�}I�h -'-a P}
` CHECK IF SUPERVISED GRADING ' •�'
❑ l am exempt from the licensing requirements as I am a 55GNATU
licensed architect w a registered professioncl engineer OF APPLICANT
actrlg in my professional capacity(Section 7051 Businesst TEL
anid Professions Code) ADDRESS ,I
SUI BOND -
Lic or Reg No Date BOND NO
HOME OWNER BUILDFR DECLARATION SURETY ` S LEEYj
1 her ntr
P
affirm ?hot I am exempt from the Cooctoi iiL
s License COMPANY nP [ !,t
1 J I
DATE REC D
Law for the following reason (Section 7031 5 Business and Pro
sessions Code) FILED
ASH , rRKD DATE
El 1, as owner of the property or my employees with wages DEPOSIT f i �r eY ��� ^^.r FILED
as thea sole compensation, will do the work and the strut THIS IS A LIMITED TIME PERMIT
lure o not intended or offered for sale (Section 7044
Business and Professions Code) I ALL WORK AUTHORIZED MUST BE COMPLETED BY
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Section TIME LIMIT: F':•L•. �.- �)'i,)..'o.
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 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 f ,� C/ U Permit Fee
Lender's Name
Lender's Address
e Issuance Fee
_
I certify that I hove 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 property for Inspection purposes _ SEE REVERSE FOR FXPLANATORY LANGUAGE
_.i A { , `(->r 7 - 1 7
Signature of Permits e ' Date f