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Home My Public Portal About6042-6044 TEMPLE CITY BLVD_Grading__ I WORKERS'COMPENSATION.DECLARATION � 76A641 .80) APPLICATION FOR GRADING PERMIT . I hereby affirm that I have a certificate of consent to self CE 807 (REV2 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 ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN SITE /1 ADDRESS CJG` �^— ❑ Certified copy is filed with the county building inspection FNBERSMk*r- SS er l LOCALITY . department. (�/�A / � Date Applicant PT IDT�Q CEOSSSTREET CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT sDISTRICT NO. IMAP NO. STATE HWY. P ED BY COMPENSATION INSURANCE NUMBER ,, Qr 9(� Y ❑ ' ❑ I OWNER PAL, SSda 4ES CUBIC YDS. This section need not be completed if the work involved MAIL HANDLED. �. Py the permit is for one hundred dollars ($100) or less.) i D ESSWA6Cft&eArrt1Lo 30 V �, TE + i 1 certify that in the performance of the work for which this CITY 14 S Ncc termit is issued, I shall not employ any person in any in U NE SPECIAL t STATE CONDITIONS O o as to become subject to the Workers'Compensation Laws. ENGINEER + r r REG.N0.2-91 U )ate Applicant 1 MADDAIL -SE H0411 & LU a IOTICE TO APPLICANT: If, after making this Certificate of ITEL rn :xemption, you should become subject to the Workers' CITY !"C 0 NO. 1Jr .78 25 :ompensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL BY Ath comply with such provisions or this permit shall be '. CONTRACTOR NO. DATE ,earned revoked. ADDRESS LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALIDATION hereby affirm that I am licensed under provisions of Chapter COMM— (commencing with Section 7000)of Division 3 of the Busi- 1 ass and Professions Code,and my license is in full force and Tact. 'icense Number Lic.Class r 3ntractor Date CHECK.IF SUPERVISED GRADING ❑ c, /t0 v Cl— SIGNATURE lySIGNATURE 7OF APPLICANT I am exempt from the licensing requirements as I am a +' licensed architect or a registered professional engineer ,� NO. $' —7 Q�25 �Z(—� acting in my professional capacity (Section 7051, Bug- ADDRESS OO l iness and Professions Code). SURETY$ BOND BOND NO. .ic.or Reg.No. Date SURETY COMPANY ") HOME OWNER-BUILDER DECLARATION FDA ED RRYC'D hereby affirm that I am exempt from the Contractor's CASH RECD DATE icense Law for the following reason (Section 7031.5, Busi- DEPOSIT$ BY FILED C ass and Professions Code): THIS IS A LIMITED TIME PERMIT I \ i 1, as owner of the property, or my employees with wages as their sole compensation, will 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' I�j+ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project EXTENDED TO: BY: \LI (Section 7044,Business and Professions Code). VV CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency EXTENDED TO: BY: V for the performance of the work for which this permit is I issued SSec.3097,Civ.C.). P.C. Fee$ Permit Fee t Lender.s Name Lender's Address Issuance Fee I I certify that I 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 building construction, and hereby authorize representatives of this County to enter i upon the above-mentioned property for inspection purposes. J SEE REVERSE FOR EXPLANATORY LANGUAGE t I Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76A641-T CE 807 (.R'E.V:2-80) APPLICATION FOR �Ri1DING PERMIT I hereby affirm that .I have a certificate. of consent to self insure,or a certificate of Workers'Compensation Insurance,or A certified.c-: .t (Sec.380.0lajye.: COUNTY OF LDS ANGELES BUILDING AND SAFETY Policy No. Con! an l '7 �'`�/ Q erdited copy is hereby furnishe FOR APPLICANT TO FILL,IN 81+E. r ADDRESS' Certified copy is filed with.the my building inspection. SITE ADDRESS _6047-_1;()4A WeraiDIgn 0J.-H.? LOCALITY dear e.-. pp�p-�AA LOT {-�'� Date App.'licant. ✓+�A. NUMBERS 2 �`-"r'�-e :Bt-Y7C�IC _ NEAREST RE T - T E CERTIF.C'ATT OF.EXEMPTION FROM WORKERS' TRACT DI RIOT O. MA N.O STATEHWY. P OCESSED-BY TUM CER z 35 COMPENSATION INSURANCE — ,. ��G=. YES p NO ' feted if the work involved OWNER ggOClA'tes' A Ltd Part. CUBIC YDS. >_ This section need not be completed MAIL HANDLED: 0. ($lOO) Or less.) ,� D.E iy the permit :is for one hundred dollars U .. . ... - certify.that in the. performance of the,work.for Which this CITY `. •.:NOL � 1470 iermit is issued, I shall.not.employ any person in•.any manner p US , O. SPECIAL lcc STATE CONDITIONS �J' % o as to become subject to:the Workers'Compensation Laws. ENGINEER REG.NO. 30343 / )ate Applicant MAIL _ s / �: LU c� a dOTIC.E TO APPLICANT..If, after-making this Certificate of 1: : TEL./ _ z EExemption, you should'. :become subject to the Workers' Z t@ 'ornpensation provisions.of the,Labor Code:;you must forth- C ° FIAT L. By ITY Dlla Calif. . No... 213a 35'9 4'5]:1: GRADING TE:L.jj�� tj t vit:h comply with such provisions or this ;permit shall .be N: RACTO..Rl. L� NO... / / s D leemed revoked. f t r� J�y i n ff�� E' , AD.DR.ESS Li.C'I G�!'[ �� '�'�/�1Q �14Tf Q�41 .. LICENSED CO.N.TRACTORS.DECLARATION PROPOSED USE OF:GRADED SITE(S) VALIDATION hereby affirm that f am licensed under provisions of Chapter 1 (commencing with Section 7000.)of Division 3 of the.Susi'- ill a ; 'ess and.Professions Code, and my.License,is:in full force and BUiMj ng S1tE ffect. icense Number / O Lic.Class �/ `rte ontracton6W/A�'A v1� /�>IPFe_r CAI? CHECK IFSUPERVISED•GRADING , IGNATURE eA t 7OF APPLICANT I am exempt from the-licensing requirements as I am a TEL , licensed architect or a registered professional engineer > acting' in my professional capacity ADDRESS NO: P Y (Section 7051, -Aug- $ BOND mess and Professions;Code). BOND -NO: Lic.or Reg.No. Date. SURETY. COMPANY �t HOME.OWNER-BUILDER DECLARATION FILED BYC'D hereby affirm that I •am. exempt from. the Contract'or's' CASH RE•C'D DATE 0 0 0 1 fi ,icense Law for :the following reason (Sectiion 703:1:5, Biisi- DEPOS`IT'$ BY F'ILE'D Less and:Professions Code)-. THIS ] 'I, as owner of the property, or my employees with L THIS IS A LIMITED TIME PERMIT ! L ° `� (� Wages as theirsole compensation, will do the. work ALL WORK AU.T.H:ORIZED MUST BE COMPLE:TE.D'BY l; o' c. 7 G C, and the structure is not intended: or -offered for sale (Section 704.4,13usiness'and.Professions Code). TIME LIMIT' sl J I;as owner of the property,, am exclusively contracting. 1 .c2.4 - 1 v4th licensed contractors to construct the project ' (Section 7044;.Business.and Professions Code); EXTENDED TO 616: I YI CONSTRUCTION;LENDING AGENCY EXTENDED TO: BV: I hereby affirm that there is.ai construction lending agency _ - - for the performance of :the work for which this permit is ( dte' r .o• issued SSec.'3: 97,Civ.C.). i P.C.Fee$ Permit.Fee �rf Lender...N'am� � . i Issuance Fee' Lender's:Addressi i Q �1 I certify that, I:have read this application and state-that. the '.S Total Fee _ LL I._ J + I above i:nf' ion is correct.I agree to comply with all.CountY . `fit f ordinances d State .laws r.elatng:to building,construction,. I' �s • and hereby u oriyg represent .:ive3 of tbis;.County to enter :upon the v'- e do 'ed pe:ty for inspeeE ory.pu po 's. t SEE REVERSE FOR EXPLANATORY LANGUAGE Z c'. . (� I Siginkfure . .'Permittee: Dote ff