HomeMy WebLinkAbout3970AWORKERS' COMPENSATION DECLARATION
I hereby affirm that l have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
Policy NWrT—�1 Qr A—' 7Company c
❑=Mis,���
S Certified copy is hereby furnished.+
Certified copy is filed with the county building inspec-
tion department.
Date 6/2 C) 81 ' 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 B-1
Contractor Carlsberg Cons,t. 0cq 9l2/82
I am exempt from the licensing requirements as l am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
ElI, 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 Bank of Cal i,fornia
Lender's Address 550 S. Plower, L.A. CA 90017
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 State laws relating to building construction,
and hereby authorize representative of this County to enter
upon above -mentioned, r.pert for inspectionipurpjbses.
v
CJ0UNIY CIF LOS ANGELES BUILDING AND SAFETY
11d1 . TVpe 16 Units 12 1 /3 /4 & /5
FOR APPLICANT TO FILL IN
BUILDING „
ADDRESS. � �� l ek'. A'-�
BUILDING
r
ADDRESS
LOCALITY
NEAREST /
CITY Ilia, 1 7A r,CROSS
ST. t®! r _,. �✓! -r_ -��. Z°
CAZIP9
O e NO. OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT
MAP BOOK
PAGE
PARCEL
TRACT PM 14534
BLOCK
LOT NO. 1
USE ZONE
r�
MAP
NO. J ��
TEL.
SPECIAL
OWNER C O NO. Z� —
CONDITIONS
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
ADDRESS 280.0 28th Street
CONST ..
ZONE.
CITY ZIP 90405
STATISTICAL CLASSIFICATION APT. CONDO.
CLASS NO. DWELL. UNITS
SEWER MAP
BK. PG VALIDATION
ARCHITECT Tasadena Design AssQ�. 793-9201
ENGINEER g
ADDRESS 1041 E. Green'St.4 Pasadena CA
Carlsberg onsCt 213 )
CONTRACTOR . IVO.'
LIC.
ADDRESS NO.
VALUATION
$ 276 000
MINNEEM
FINAL J 9 7, 0 A
CITY Santa Monica, CA aaSS B-1
SO FT.
SIZE 6 8O8
NO. OF
STORIES 2
NO. OF
FAMILIES 4
CHECK
ONE
DESCRIPTION OF WORK
NEW O
Wood frame- townhouses
ADD
ALTER
s'e,fe_ev) )® '44_,J:vl ,che•'t:
REPAIR
DATE
FINAL, • • • • 2 8
USE OF
EXISTING BLDG. N/A
DEMOL
By 1 ®2 6 3' 0 4
APPLICANT TEL
Carlber Const. • Co 450-6800
s g
(PRINT) NO.
®2 6 3, 4
ADDRESS 2800 28th St., Santa Monica, CA
09, 0.9 — 8 2
PRESENT
/1
(i //
BUILDING
ADDRESS
LOCALITY
( d
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 $ ' .i to "`
Permit Fee
Issuance Fee
Investigation Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Age (t