HomeMy Public PortalAbout5561 SULTANA AVE_Grading__ 1VORK.ERS COMPENSATION OECse CE 807 (REV280) APPLICATION FOR GRADING 1ERMIT
I hercb> affirm that I have a certificatee of of consent to self
msurt;yr e certificate of Workers'Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No C9�s Company-STATE MINI)
Certified copy n hereby furnished FOR APPLICANT TO FILL IN SITE
ADDRESS
ISI F� Certified copy is filed with the vu budding inspection SITE ADQBESE' 11 ca LOCALITY
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de a e t t v LOTJ�
Date Applicant NUMBERS d- BLOCK NEAREST
CER I CATE OF EXEMPT N FROM WORKERS - NRA BER �/ a DIST _{fir M P NO ATE HWV P D BY
COMPENSATION NSURANCE s
(Thu section need not be completed If the wort mVolVad OWNEss 1442R R- Va3 CL
ER CUBIC VDS
by the permit u for One handled dOBars (5100) Or lea) MAILley Blvd- HANDLE Y
76 0
I certify that in the performance of the work for which this V CITY C3_ty Of '-"""""-�I N0 18-330-7886
permit ,s issued, I shall not employ an TrbSPECIAL
p p y y person in any manner STATE CONDITIONS S
so as to become subject to the Workers Compensation Laws ENGINEER REO NO ir
Date Applicant MAIL F
NOTICE TO APPLICANT If after making this Certificate of V CITY TSL d
Exemption you should become subject to the Workers N to
Compensation provisions of the Labor Code you must forth GRADING TREE ER TEL 213 515— FINAL BY Z
with comply with such provisions or this permit shell beCONTRACTQRDATE B �y�
deemed revoked ADDRESS d
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITES) VALIDATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi
ness and Professions Code, and my license is in full force and
effect
License Number 329846 Lm Class a
Contractor ate CHECK IF SUPERVISED GRADING ��i336i�10
U 1 am xempi from the licensing requirements as I am a OF APPLICANT I A 41,
J /CCII
licensed architect or a registered professional engineer ADDRESS TOL —
acting in my professional capacity (Section 7051, Bus
mos and Professions Cade) SUREBONO Y$ Q ss NO Q']q I
Lm or Reg No Date SURETY
COMPANYfiv&WLSad I
HOME OWNER BUILDER DECLARATION DATE RE
C D
FILED BY g9583A
1 hereby affirm that 1 em exempt from the Contractor's CASH REC D DATE
License Law for the following reason (Section 7031 5, Bus, DEPOSIT$ BY FILED # a a a a 04
ness and Professions Code) THIS IS A LIMITED TIME PERMIT
1 as owner of the property or my employees with - ,) - 34a50
wages as their sole compensation will do the work ALL WORK AUTHORIZED MUST BE COMPLETED BY S
and the structure is not intended or offered for sale • - 34050S 3 4 0 5 0
(Section 7044 Business and Professions Code) TIME LIMIT 0 5. 31 —88
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project EXTENDED TO r BY
(Section 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY EXTENDED TO BY
I hereby affirm that there ,s a construction lending agency
for the performance of the work for which this permit ,s /' 2 2
issued(Sec 3097 Civ C ) PC Fee$ �.(/ Permit Fee 3 JQ
Lenders Name Te] :Rank 2€ foR-1-3 E tT,';,-
' I '
Lender s Address3";3 ij_ Al arrrsAa r T.-A- CA 0Issuance Fee J(�013 3 /7-/V/7r
I certify that I have read this application and state that the Total Fee 3 Or
above information,s correct I agree to comply with all County
ordinances and State laws relating to budding construction - t
and hereby authonre representatives of this County to enter
uponI�bw/in it prop�nspectionArA s SEE REVERSE FOR EXPLANATORY LANGUAGE
Signet a of ermittee _ Date /7S 7[ -