HomeMy WebLinkAbout9695A.,r,ENSATION DECLARATION
.,at I have a certificate Blae of consent to self 27 APPLICATION PERMIT
ertificote of Workers'' Compensation ensaffon Insurance, g.
.,stied copy thereof (Sec. 3800, Lob. C.) Units 90,91,92,93, COUNTY OF LOS ANGELES BUILDING AND SAFETY
policy NJWC1553546CompanyFred. S.James &Co.
Certified copy is hereby furnished.
®Certified copy is filed with the county building inspec-
tion department.
Date 4/1/85 Applicant Carlsberg Const.Co.
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 Nvmber 317917 Lic. Class —�
ContractorI21 1shi= Const_to 4/1,11A5
I am exempt under Sec.
B,&P.C. for this reason
Dote:
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):
DI, 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 hove 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.
I "M 711111BUILDING
FOR APPLICANT TO FILL IN
IN
S
BUILDING
ADDRESS 3040 1,a Paz Lane
TY
CITY Diamond Bar ZIP 91765ST.
T
One Lot
NO. OF BLDGS. None
OR
SIZE OF LOT
NOW ON LOT
OK
PAGE
PARCEL
TRACT PM1.4534
BLOCK
LOT N
INARE
NE
OP
TEL.
OWNER Carlsberg COnst.CO. NO.
SPECIAL
CONDITIONS
ICT
GROUP TYPE FIRE PROCESSED BY
ADDRESS 2800 28th St.
CONST. ZONE
CITY Santa Monica zip 90405ARCHITECT
OR TEL .e 49S
Vito Cetta AIA
ICAL CLASSIFICATION APT. CONDO.ENGINEER
No.4
NO.
DWELL, UNITS--
AUUKtZO 1Y.1.7 G11.A aP—OCULI Uct
CONTRACTOR Carlsberg COnst.
ADDRESS 2800 28th St.
CITY Santa Monica
SQ. FT. L. NO. OF
SV_E SMPlFS 2
USE OF
v7v t Jt WtK MAY
ifi(1 BK. PG,
No. 317 237
LIC.B-1
CLASS
NO. OF
4
CHECK
FAMILIES
ONE
NEW
ADD
ALTER
El
REPAIR
0
DEMOL
F1
APPLICANT TEL 413
PRINT Carlsberg COnStvCO. NO. 50- 800
2800 28th St.Santa Monica,Ca.904
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
FRONT
P. L.
SIDE
P. L.
P.C. Fee $ Permit Fee
p
p
Issuance Fee
snvesnganon ree
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
VALUATION
$22001
$
FINAL
DATE
FINAL
By
u
VALIDATION
'969.5A
01111.
#9**o23
�1-891,23
® e891.230'
05.06-85
0
U
C�
tj
r�.
Signature of Applicant or Agent Date
06