HomeMy Public PortalAbout5602 WELLAND AVE_Grading__ WORKERS.'COMPENSATION•DECLARATION 76A641T .
CE 807 (RE'V.'2-80) APP -ATI-0111 FORGRADING PERMIT
!!*hereby affirm that I have a certificate. of consent to self
insure,or a certificate of Workers'CoA�satInsurance . ��.i
Flip c p t ere ec 3900,La ' COUNTY 0- L.OS A ES � BUILDING AND SAFETY t
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�ffitcy o: Company
❑. Certified.copy is hereby furnished. FOR APPLICANT TO FILL.I.N SITE.
O __/_` c1-�. _ ADDRESS-] O �f•✓� �Gr�
Certified copy is filed with the county build' g inspection SITE E ., �f) �ANp LOCALITY E�1 +
d'epartment,�
LOT ,A
Date Applicant, NU BE�,RS I BLOCK NEAREST.
R RS S RE T (
A T
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T E
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT MAP NO: STATE'HWY. PROCESSED BY y'
COMPENSATION INSURANCE NUMBER sY ,Tpl�� �(,9 / j �} Y ❑` O
This section need.not be completed if the work involved O.W N E R C�-0•-A 1- C UB Y DS'
p HANDLED:: '
MIL �-
iy the permit is for one hundred. dollars s ( 100) or Less:) D .E �s .. U tJ- . 'J'��J U„
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certify that in the performance of the work.for which this TEL.
CITY•. NO US . CONDITIONS,
2 SPECIAL ,
ON
iermit is issued, I shall not employ any person in any manner. �
. �
o as to become subject to the Workers?Compensation Laws. ENGINEER STA'T'E'
REG.NO rF V "
)ate' Applicant i AMALESSf-01, E. IC11 Wa
IOTICE.TO APPLICANT: If, after making this Certificate of. TEBL to
•�.
ixemptian, you should, become .subject to the Workers', CITY N
.ompensation provision's.of'the Labor Code.i you must.forth- GRADING'-.. c.t TE L./J.2� g��1 FINAL [BY
vith comply with such CONTR TOR �JS.�•' N.O. b5 40. I DATE
p y provisions or this permit shall be
eemed revoked.
ADDRESS'. ' . .
LICENSED CONTRACTORS DECLARATION i 'PROPOSED USE.OF GRADED SITE(S), " VALI-DATION
hereby affirm.that I am licensed under provisions of Chapter
(commencing with Section 7000)of Division,3.of the Busi- Wtu, 6.. C-r
ess and Professions Cdde.,and my license.is in.full force and V .
Ffect.
[cense Number 32 I
�7jLic.Class �^
�ntra�o A' KMS Date p % C7 CHECK IFS,UPE.VIS,' GR •ING "
_ 4 _ S G ATU.RE. I'
I am exempt from the licensing requirements as'.I am a OF,APPLICA
licensed architect or a registered :profess one en neer Z W. E _ L . TEL. i
g P �.. A•DDR'ES G NQ, a,11
acting in my professional capacity (Section 7051, Bug-
iness and Professions Code). BOND Y$ BOND
..
,id.or Reg..No.- Date SURETY
COMPANY
HOME OWNER-BUILDER DECLARATION PILED BYC'D
hereby affirm that I. am exempt. from the .Contractor's CASH RE.C'D DATE t
icense Law for the following reason (Section 7031.5, Busi- DEPOSIT$ QY FILE'D
ass and.Professions Code).-
"
THIS-IS A LIMITED TIME PERMIT
1, as. owner .of the property, or my employees with I
wages. as their sole compensation, will 'do 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). I
4 TIME' LIMIT: `
I, as owner of the property, am exclusively contracting r
with licensed contractors to construct the project ,EXTENDED TO: BY:
(Section 7044,Business and Professions Code.).
CONSTRUCTION.LENDIN.G AGENCY E•XTEND.ED TO: BYi
I' hereby affirm that there is a construction Tending agency
for the performance of. the work for which this permit is 7
issued(Sec.3097,Civ.C.). P.C. Fee$ L ( Permit Fee i
Lender's Name
Lender's Address Issuance Fee f
I certify that I have read'this application and state that the Total Fee
above information is,correct.I agree.to comply With all C-.o.unfiy
ordinances and State laws relating to building construction.,
and hereby authorize.representatives•of this County to enter
upon the above-mentioned property for inspection.purposes.. �,SEE REVERSE FOR EXPLANATORY LANGUAGE ' l
Signature of Permittee Date ;