HomeMy Public PortalAbout5403 WELLAND AVE_Grading__ I
WORKERS'COMPENSATION DECLARATION 76A641T APPLICATION FOR GRADING PERMIT
I hereby affirm that I have a certificate of consent to self CE 807 (REV.2-80)
insure+or a certificate of Workers'CompensaZ;F-
qertified
,or
a cert f�ije�d, hpr (Sec.3800,Lab ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
yd! ompany copy.is hereby furnished. FOR APPLICANT TO FILL IN SITE 0"i-
' w� � /�`/ ADDRESS
Certs ed c y is filed with the cq ty building inspection SITE E S ^`� f�wA�(� �i� LOCALITY
NEAREST
Date Applicant _ NUMBERS BLOCK CROSS STREET
C RTI CATE OF EXEMPTION FROM WORKERS' tem— ' �, �d�Lr DISTR,�CT �NZO� STA E H YES 0 O PROC BY
COMPENSATION INSURANCE UMBER�n '
(This section need not be completed if the work involved OW N E Rt�I1;t� 6L 'J �Tf2iJG1 101%J
p CUBIC YDS. IL
by the permit is for one hundred dollars ($100) or less.) A D D MAIL E �j'aj�' 2�'Lk- � HANDLED: V
l certify that in the performance of the work for which this CITY Vt A4- ck NOL 7 5`7'3 2-11tr
permit is issued, I shall not employ any person in any manner USE NE SPECIAL
/I,,,,�t, STATE. CONDITIONS 0
;o as to become subject to the Workers'Compensation Laws. ENGINEER M . . REG.NO.
PP MAI L N— � .. a
Uate ApplicantADORES
NOTICE TO APPLICANT: If, after.making this Certificate of CITY rc— Ci NEO ' ( fn
Exemption, you should become subject to the Workers'
compensation provisions of the Labor Code, you must forth- GRADING TEL. FINAL BY
Nith comply with such provisions or thisermit shall be CONTRACTOR NO. DATE ,,
seemed revoked. P �'5 ,
ADDRESS
LICENSED CONTRACTORS DECLARATION PROPOSED USE OF GRADED SITE(S) VALI__ [}ASIflAJ_ p
hereby affirm that I am licensed under provisions of Chapter L);ham �nC� �iJd
(commencing with Section 7000)of Division 3 of the Busi• # o o o o 18
ess and Professions Code, and my license is in_full force and o2-4Q00
ffect.
icense Numbers 6 j c.Class a o o 2 4 Q 0 0 5
ontractor Date CHECK IF SUPERVISE pRADING. .1 a26-87
_ SIGNATURE
I am exempt from the. licensing requirements as I am a OF APPLICANT
licensed architect or a registered professional engineer TEL.q
acting in my professional capacity (Section 7051, Bus-
ADDRESS NO.
iness and Professions Code). SURETY$ BOND
BOND NO.
Lic.or Reg.No. Date SURETY
COMPANY
HOME OWNER-BUILDER DECLARATION PILED BRYC'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 19161 A
ess and Professions Code): THIS IS A LIMITED TIME PERMIT
I, as owner of the property, or my employees with # 0 0 0 0 0 4
wages as their sole compensation, will do the work ALL WORK AUTHORIZED MUST BE COMPLETED BY I
and the structure is not intended or offered for sale, ,•,
(Section 7044,Business and Professions Code). I I! o G 5 Q 5 0
I, as owner of the property, am exclusively contracting r, r
wiTIME LIMIT:
th licensed contractors to construct the project 0 0
(Section 7044,Business and Professions Code). EXTENDED TO: BY: r
CONSTRUCTION LENDING AGENCY (; j LI -0 S
I hereby affirm that there is a construction lending agency
' EXTENDED TO: BY:
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). P.C.Fee$ QVIO,0 6 Permit Fee
Lender's Name
Jpnder's Address
Issuance Fee
I'Jdinanc
ifI hav read this application and state that the Total Fee
a� a ' is rrect.1 agree to comply with all County
grd Stat laws relating to building construction,
anuthor' a representatives of this County to ter
upin do ed property for in t' pur o I SEE REVERSE FOR EXPLANATORY LANGUAGE
I
S lure of P. ittee Date