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HomeMy WebLinkAbout9692A...cRS' COMPENSATION DECLARATION affirm that I have a certificate of consent to self"IN FOR BUILDING PERMIT .,re, or a certificate of Workers' Compensation Insurance, P" PLICATIO or a certified copy thereof (Sec. 3800, Lab. C. Bldg.19 Policy No._ 5C15535 &mponyFred S.JaITes & C:O.Uni'tS 59,60,61,62 COUNTY OF LOS ANGELES BUILDING AND SAFETY ® Certified copy is hereby furnished ®Certified copy is filed with the county building inspec- tion department. Date Anr7 1 1 -I �lic ant C'ar_ n Sf CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 317237 Li[. Goss B-1 _ Contractor Carl sberct ConSt.Qe 4Zl 1 am exempt under Sec. B.dP.C. for this reason Date: Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and Professions Code): ® I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not Intended or offered for sale (Section 7044, Business and Professions Code). ® I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ISec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the 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 for inspection purposes, FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS 3025 La Paz Lane LOCALITY CITY Diclmond Bar 91765 NEAREST Zip CROSS ST. t (O. QF BLDGS. SIZE OF LOTpne Lo 1 OT_ ASSESSOR MAP BOOK PAGE PARCEL TRACT M145 BLOCK LOT NO. USE ZONE MAP NO. TEL OWNERCarlsber'C,[ COnst.Co. NO SPECIAL I CONDITIONS _ 2800 28th St. DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS CONST. ZONE CITY S pt-a Nhpir ZIP � ARCHITECT OR Vito Cetta AIA TEL _ STATISTICAL CLASSIFICATION APT. CONDO. ENGINEER NO.451-8491 CLASS NO..___,DWELL, UNITS—M_ ADDRESS 1419 2nd St. Santa Monica, Ca.90 SEWEk MAP BK. PG, VALIDATION CONTRACTOR /� �.�,TE,L�. 213) 5}{��7J(� ADDRESS 2800 28th St. ". 3172.37 --- VALUATION cLTY Santa Monica B�1 ci. $ 344 SQ. FT. NO. OF NO OF CHECK 2 9 6 9. 2 A SIZE STORIES FAMILIES _ ONE USE OF NEW ADD El ALTER REPAIR [J rL DEMOL 1 , f'JPRr'ryCarlSberCf COrist • Co i TEL. k Zl3) =4�U"' PINTI c nnn MOVING ADDRFSS 2800 28-111 St. Santa Monica,Ca.9 TEL. YARD HWY TOTAL SETBACK FROM PROP. LINE EXIST. WIDTH PEIED Permit Foe Issuance Fee d C, Total F--©e SEE REVERSE FOR EXPLANATORY LANGUAGE -Y �t2i styi) FINAL DATE FINAL By El f� q ° ° ° ;� 6 I ° % 50,60 ° 750,60xo 05,06--85 Signolure of Applicant or Agent Date