HomeMy WebLinkAbout8837A..,LION DECLARATION �w
gave a certificate of consent to self A P P L I CAT I ®ICI ■OR
_ate of Workers' Compensation Insurance, Bldg. 25
00*
opy thereof (Sec. 3800, Lab. C. )
yNo. � 1553�o6panyFred S.Ja s & CO.Units ,82,83,84,000NTY OF LOS ANGELES
(' Certified copy is hereby furnished, FOR APPLICANT TO FILL IN
®Certified copy is filed with the county building inspec- BUILDING i
tion department. ADDRESS — 4A ref 404
Date 3/1$r/R5 Applicant CO. CITY DiaWnd Bar ZIP 91765
CERTIFICATE OF EXEMPTION FROM WORKERS' NO, OF BLDGS.
COMPENSATION INSURANCE SIZE OF LOT ; NOW ON LOT None
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO.
hundred dollars ($100) or less.)
TEL.
I certify that in the performance of the work for which this OWNER Carlsberg COnSt.CO. NO.
permit is Issued, I shall not employ any person in any manner ADDRESS 2800 28tth St.
so as to become subject to the Workers' Compensation Laws. .
Dale 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 Llc. Class B-1
Contractor _Carl cberrr C'nnei- _[67r _ 3/18/85
❑ I am exempt under Sec.
B.&P,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):
❑ 1, 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 offirm that there is a construction lending agency for
the performance of the work for which this permit is issued
ISec. 3097, Civ. C. ).
m
Lender's Name
Lender's Address _
1 certify that I have read this application and state that the
above information is correct, I agree to comply with all County
ordinances and Stole laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
BUILDING PERMIT
BUILDING AND SAFETY
BUILDING
ADDRESS
NEAREST
CROSS ST.
ASSESSOR
MAP BOOK
GROUP (TYPEE I FIRE
CONST. ZONE
CITY 6anta moraca ZIP VU4W)
ARCHITECT TEL. / `
STATISTICAL CLASSIFICATTIION
APT. CONDO.
ENGINEER lto Cetta NO.1 /
CLASS NO. t�1 ` -DWELL UNITS
ADDRESS 1419 2nd St.Santa Monica Ca.9040
SEWER MAP
TEL. (213) 450—
CONTRACTOR Carlsberg COTS .CO. NO. 6800
BK. PG,
VALIDATION
ADDRESS 2800 28th St. No.317237
VALUATION
LIC,'
CITY iCLASS e
$
IZSIZEFb
8 7I1
950 TORIOES 2 AMILLIIES 5 ONE
NEW
$
• s • •
# 2 3
DESCRIPTION OF WORK IytJ
ADD ❑
I • 999,b0
s ALTER ❑
FINAL
I ®1 ,l 7,
REPAIR ❑
DATE
,
USE OF
EXISTIING BLDG, N/A DEMOL ❑
FINAL
• �, 7 8 ,
APPLICANT TEL 1 ) —
6y
3, 2 2 " 8
(PRINT) Carl �11PYQ CO R n NO.
.
ADDRESS _2.800 28th St.Santa Monica,Ca.904
MOVING TEL.
CONTRACTOR NO.
ArMPFts
REQUIRED
YARD
HWY
TOTAL SETBACK FROM
EXIST.
SET BACK
PROP. LINE
WIDTH
FRONT
P. L.
SIDE
P.L.
�/ a
P.C. Fee S 11 / �. O 3
Permit Fee
Issuance Fee
Investigation Fee
Total Fee
n
Signature of Applicant or Agent
Date
SEE REVERSE FOR EXPLANATORY LANGUAGE
i