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WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have certificate of consent to self APPLICATION p
insure, or a certificate of Workers' Compensation Insurance, PERMIT
or a certified copy thereof (Sec: 3800, Lab. C.) Bldg. 22,
Policy No. 1553546 Company TngiTrancaUnit No.70 71 COUNTY OF LOS ANGELES BUILDING AND SAFETY
P
Certified copy is hereby furnished.
®Certified copy is filed with the county building inspec-
tion department.
Date 1Z28/85 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 Number 317237 Lic: Class R-1
Contractor C'ar1 Shf-J= CO -Date 1-1/28,185
I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby off irm that I am exempt from the Contractor's License
Law 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
(Sec. 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
3001 la. Paz bane 7
1,CROSS
ADDRESS
LOCALITY
CITY Diamond Bar ZIP 91765
NEAREST
ST.
NO. OF
SIZE OF LOT One Lot SUb, NOW ON LOTS None
ASSESOR
MAP BOOK
I
PAGE
PARCEL
TRACT 14534 BLOCK LOT NO.
USE ZONE
MAP
NO.
CONDITIONS
OWNER Carlsberg Const. CO. NO. 00
2800 28th Street
DISTRICT
GROUP TTYPE FIRE
CONST. ZONE
PROCESSED BY
ADDRESS
CITY ZIP 4
ARCHITECT O TEL. _
STATISTICAL CLASSIFICATION
APT.
ENGINEER Ito Cetta AM NO.
CLASS NO.
DWELL. UNITS
JCONDO.
ADDRESS 1419 2nd St. Santa Monica, 90401
SEWER MAP
CONTRACTOR arlSber OnSt.CO DLO. 21 0�
BK•
PG,
VALIDATION
LIC
ADDREss2800 28th St. 317237
No.
VALUATION
Ll
CITY iCLASS —
$ 160 800
2 77 LI, 7A
SQ. FT. NO. OF NO OF CHECK
4020 2 2
SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK NEW
I s 6 1 H
ADD
food FrameWY)11Ct[L1eS
ALTER
FINAL
• i b 0 8 118
REPAIR
DATE
AZ 5
USE OF
EXISTING BLDG. N A DEMOL
/
FINAL
By
APPLpRINT ar Sber COASt.CO. NO, 3 0_
Sno
ADDRESS 2800 28th St.Santa Monica 90405
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
C NTRACTOR NO.
ADDRESS
REQUIRED HWY TOTAL SETBACK FROM EXIST.
SET BACK YARD PROP. LINE WIDTH
FRONT
P.L.
SIDE
P.L.
P.C. Fee $ C/"i� a Permit Fee
Issuance Fee
Investigation Fee
Total Fee
f�
O
LJ
tY
Q
n
Signature of Applicant or Agent Date
SEE REVERSE FOR EXPLANATORY LANGUAGE
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