HomeMy WebLinkAbout7749A (2)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. 1553546 company Nome Insurance
Certified copy is hereby furnished.
®Certified copy is filed with the county building inspec-
tion department,
APPLICATION FOR BUILDING PERMIT�
Bidg.23
Co.Unit 72,73,74,75 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Datel/28/85 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 -;�� Llc. Class�T�
Contractor0irl shE�rg Cons ..(ate 1 /28/8_
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
tSec. 3097, Civ. C. ).
Lender's Nome
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 3000 La Paz Lane
ADDRESS
LOCALITY
NEAREST
CITY Dicainnd Bar ZIP 91765
CROSS ST.
NO OF BLDGS.
SIZE OF LOT One Lot Sub. NOW ON LOT None
ASSESSOR
MAP BOOK
PAGE
PARCEL
TRACT 14534
BLOCK LOT NO.
USE ZONE
MAP
NO.
TEL. —
OWNER Carlsberg Const.Co. NO Son
SPECIAL
CONDITIONS
DISTRICT
GROUP TYPE FIRE
PROCESSED BY
ADDRESS -
CONST. ZONE
I
CITY Santa Monica ZIP 90405
V1
ARCHITECT OR TEL.
STATISTICAL CLASSIFICATION
APT.TWDJ0.
ENGINEER Vito Cetta AIA NO. 213 451-
CLASS NO.
DWELL. UNITS
ADDRESS 1419 2nd St.Santa Monica, 8491
SEWER MAP
TEL
CONTRACTOR Carlsber COnst.Con,O.
BK.
PG
VALIDATION
ADDRESS2800 28th St. No'. 317237
VALUATION
LIC,
CITY 4 cLAssB-1
$ 292 640
z 7 7 CI 9 A
SQ,FT. NO. OF NO OF CHECK
7316 2 4
SIZE STORIES FAMILIES ONE
$f••••23
DESCRIPTION OF WORK NEW
ADD ❑
i • 944,78
ALTER ❑
FINAL
•• 9 4 U, 7 8 11
REPAIR ❑
DATE
USE of
EXISTING BLDG. N/A DEMOL ❑
FINAL
0 1, 2 9" 8 5
APPLICANT TEL,1 A50—
By
PRINTCarlsberg Cons.CO• NO.
ADDRESS 2800 28th St.Santa Monica 90405
PRESE T
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED TOTAL SETBACK FROM EXIST.
SET BACK YARD HWY PROP, LINT: WIDTH
FRONT
P. L.
SIDE
P.L.
l Q
P.C. Fee $ 0 Permh Fee
Issuance Fee
Investigation Fee
Total Fee
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date ®s