HomeMy Public PortalAbout5722 A-E TEMPLE CITY BLVD_Grading__ WORKFRS'COSIPFNSA I ION DFCI ARA]ION 7EAA.1T ` v`` 1` `\ \ ,j6 r wO ,
I hereby affirm that I have a cMihcate of consent to self insets CF 807(REV z B „
OD,BO - APPLICATION FOR GRADING PERMIT
or a certificate of Workers Compensation Insurance or a car ,L
lifted copy thereof(Sec 38x0 Lob C ) COUNTY OF LOS ANGELES ; Y 2 WADING AND\SAFETY
Policy No -- Company sro-n� xrJ.ua l
. SITE
❑ Certified copy ii S
hereby furnished FOR APPLICANT TO FILL IN ADDRESS �a
copy county 9 P� AADDDRESS 2 j LOCALITY O
C ❑ Certified c a filed with the tours building inspection V
q '
department LOT /�� NEAREST C
TRACT
.Date u�d d9 Applicant NUMBERS !!i(/ BLOCK CROSS STREET C
CERTIFICATE OF FXFINPTION FRONT WORKERS NUMBER
SNo STATE tIWY
COMPENSATION INSURANCF YES O NO O CL
W
OWNERr �I �� CUBIC YDS I _
(This section need not be completed If the work Involved by MAIL
RE55 2 r h '. HANDLED ////����
the permit b for one hundred dollars($100)or loss ) (it/.
1. TEL 3_ /
I certify that in the performonce of the work for which this per- CIN Y7 Z SPEgAL
mit is issued I shall not employ any person in any manner so as SDS CONDITIONS
to become subject to the Workers'Compensation Laws ENGINEER
MAR 3�Z to
Dote Applicant ADDRESS l /�-�,
NOTICE TO APPLICANT If, after making this Certificate of Ex �, /l E10L 12t W
emphon, you should become subject to the Workeri Compen- GRADING TEL FINAL BY
lotion provisions of the Labor Code you must forthwith comply GRADINCTOg 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) VALIDATION
(commencing with Section 7000) of Division 3 of the Business v�� Tyl7 c77 c��
and Professions Code, and my license is in full force and effect
License Number La Class , I TTCMQ
Contracts Date TO r41 XC?_?
CHECK IF SUPERMIXD GRADING �: 4� rit (K.1 `•12.50
❑ I am exempt from the licensing requirements as I am a S ..
licensed architect or a registered professional engineer OF APPLICANT '. 1ruGUfF f11]
acting in my professional capacity (Section 7051, Busineu - ITEC
and Professions Code) ADDRESS
SURETY S BOND \\L
Lic sReg No Dote BOND NOtrnn,dip i/,71/Pg
HOME OWNER.BUILDFR DECLARATION SURETY
NY v nD 17 T &,i s•e,
I hereby affirm that I am exempt from the Contractors License DATE RK D 4
Law for the following reason(Section 7031 5 Business and Pro FLIED BY i
fessions Code) CASH RECD DATE T
❑ 1 as owner of the property,'or my employees with wages DEPOSIT f BY FILED '
as their sole compensation, will do the work and the struc-
ture TIME a not intended or offered for sale (Section 7044,
Business and Professions Code) ALL WORK AUTHORIZED MUST BE COMPLETED BY
I os owner of the property am exclusively contracting TIME LIMIT: TCITAL 60:3 - 017
with licensed contractors to construct the project (Section '_HCLR t11�,Q11
7044, Business and Professions Code)
CONSTRUCTION LENDING AGFNCY EXTENDED TO BY C.� uE •f((I
J herebyy vm off that there is a construction lending agency for `
the performance of the work for which this permit is issued(Sec' EXTENDED TO BY
3D97, Coo; CIPC Fee$ QO Permit Fee �r,S3 ill lel_ I 1 I)1 4/IFS I5
Lender's Nome
Issuance Fee ILO .,SU 2a'J 1 AM 9:CIII
Lender s Address D -
7rcartify that I have read this application and state that the Total 1" 60.3 a
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 I inspection purposes SEE REVERSE FOR FXPLANATORY I ANGUAGE
Si re of Permittee Dote