HomeMy Public PortalAbout5327 WELLAND AVE_Grading__ .os�Mti WORKIiItS'COM1I'I:t1SA'1'ION 01-'CLARA-1'I0N 76A641
I hereby affirm that I have a certificate of consent to self insure, CE 807(REV. 2-80)10/80 APPLICATION FOR GRADING PER*IT
or a certificate of Workers'Compensation Insurance, or a cer-
tified co y thereof(Sec. 3800,.LabCc. ) -� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po
c�
icy y NO. Company ���� \ � , ••_� _ /-•� ,
❑ Certified copy is hereby furnished. i FOR APPLICANT TO FILL IN 40AR
�-/` �^•' 'C.L..�.�"��
SITE — _ - f
�Cerlified copy is filed with the county building inspection AD a'L% �. .'LOT ' BLOCK
Date 7 Applicant_ NUMBERS CROSS STREET
TRACT DISTRICT No, MAP NO. STATE HWY. PRO ESSED BY
C HIVI'IFICA'I'l-Olr 14XIi111P'I'ION 1:R0DI WORKMIS' NUMBER /)tV
=(- r— �' 3 J/`1+�' YES❑ NO ❑ ,S B t
C:U�1111:NSA•I'ION INSIIRANCIi A-A811- (�fi� _ _/+'F/+
OWNER "^ CUBIC YDS.-
(This section need riot be completed If the work.involved by MAIL + et. _ HANDLED: /." /� f
the permit is-for one hundred dollars($100)or less.) ADDRESS '.
TEL.
I certify that in the performance of the work for which this per- , CITY NO. USE ZONE SPECIAL
mit is issued,I shall noLemploy any person in any manner so as CONDITIONS.� U
to become subject to the Workers'Compensation Laws. ENGINEER r_. "^G STATE REG. NO. 0
MAIL
Date Applicant ADDRESS (`-• - C.=�. i
NO 1'0 AI'PLICAN'I':If, after making this Certificate of Ex- CITYI TEL.
NO.
F-
emp. • .,•you should become subject to the Workers'Compen- - u�
GRADING TEL. INAL BY n-
sation provisions of the Labor Code,you must forthwith comply CONTRACTOR d' of
with such provisions or this permit shall be deemed revoked. - ) - -t- NO.v DA - +l
LICI?NSIiU CON I'ItA(:1'ORS DIiC:I.ARA'I'IUN ADDRESS _Ly^�_ -
I hereby affirm that I am licensed under provisions of Chapter 9 PROPOSED USE OF GRADED SITE(S) VALIDATION
(commencing with Section 7000) of Division 3 of the Business -��
and Professions Code and m I' ense is in full/ e and effect. -=c
License Number^�� .Class -�.�1 1- ' �� 1^I(^�r"1 'rr
^r nr.
Controctor � �Date '? �` 1r;� J�
CHECK IF SUPERVISED GRADING I!-`t y 1 j EMS
❑ 1 am exempt from the licensing requirements as I am a SIGNATURE _ �- _' -.�p2 +-•I,C•
I icensed architect or a registered professional engineer OF APPLICANT .�� 1 UTA .+-.m -a -r
acting in my professional capacity (Section 7051, Business _ rY •TEL. c7 c �•, '�..;,�
and Professions Code). ADDRESS 13. A, NO. Ci'ftf'(a' (cF�. m {���•rti +.�+ ��.
SURETY$ •,-, OND I�s
Lic.or Reg.No. Dote BOND C d (% 0. �:t-t.AIK .•
I-10NI'OWNIiRd1U11.1)FR DI?CI.ARA'1'I0N SURETY
COMPANY
I hereby affirm that I am exempt from the Contractor's License
'S is _
DATE RECD I' +.�rU-�C>�.1_••,•. '{h '��`.air
Law for the following reason(Section 7031.5, Business and Pro- t FILED BY
fessir--Code): 9� :. ::): 1�i i :4tE
CASH RECD DATE
❑ owner of the property, or my employees with wages DEPOSIT$ BY FILED -
as n;sir sole compensation,will do the work and the strut- THIS IS A LIMITED TIME PERMIT -
lure is not intended or offered for sale (Section 7044,
Business and Professions Code). ALL.WORK AUTHORIZED MUST BE COMPLETED BY
❑ 1,-as owner of the property, am exclusively contracting TIME LIMIT:
with licensed contractors to construct the project (Section
7044, Business and Professions-Code). :,.`.. "'•:_;�,,•
( CONS'1'RUC'I ION I.I-NI)ING AGIiNCY. { 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.). -/
P.C. Fee$ � i Permit Fee
Lender's Name f" Issuance Fee' all 7J \
Lender's Address ' el bi `-
I certify thai I have read this opplicaticn.and slate that the • , v? j��r11 !XT/�� Total Fe/6
above information is correct. I agree to comply with all County
ordinances and State laws•relating to building construction,and 6:
hereby
.2x11'
hereby authori P seM_a11�4es of this County, to ¢nter upon
the abov htione er1 f inspection Grp es. SI3R,REVERSE FOR EXPI-ANATORY LANGUAGE
1 na�f Iie-0 ee
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