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HomeMy WebLinkAbout8640AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compenstion Insurance, or a certified cyy thereof (Sec. 3800, Lab. C. ) Policy No.2] 955 A Company���inn Tn���, Certified copy is hereby furnished. ❑Certified copy is filed with the county building inspec- tion department. Date 6f30'/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 Numberil /ZJ / Lic. Class Contractor Carlsberg Constaate 6 29 81 ❑ I am exempt from the licensing requirements.as I 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): ❑ 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 Rank of California Lender's Address 550 S. Flower, L.A. C.A, 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 representatives of this County to enter u on th above -mentioned pr pGrty for ' spection p poses 9 i$ :: BUILDING S BUILDING AND SAFETY to .. .- � . S _. FOR APPLICANT TO FILL IN BUILDING ADDRESS �'c`) Yc'1 PL-e FBUILDING LOCALITY NEAREST ZIP CROSS ST. >' �e lot NO. OF BLDGS. ASSESSOR NOW ON LOT MAP BOOK PAGE PARCEL T PM 14534 BLOCK LOT NO. l USE ZONE NOP J SPECIAL13,) ER Carlsber Const. CO. NO. ' A CONDITIONS DISTRICT, GROUP TYPE FIRE PROCESSED BY rADDRESS2800 28th Street CONST ZONE Santa Monica, CA ZIP 90405t `�/'�ITECT OR TEL 21STATISTICAL CLASSIFICATION APT. CONDO.NEERPOladen Design ASSOCNO. CLASS NO. r°1 T- DWELL. UNITS zy. ADDRESS iygi r;. CONTRACTOR Carlsberg preen .7L. , rasaQena TEL. Const. NO. L btwtK PAAF BK. PG, LIC, ADDRESS 28 O. 3172 VALUATION CITY LIC. CLASS $ 236,700 SQ. FT. NO, OF NO. OF CHECK SIZE 7,634 STORIES 2 FAMILIES 4 ONE _-9, S [y Cf ' DESCRIPTION OF WORK NEW y ADD ❑ wood frame townhouses ALTER ❑ FINAL REPAIR ❑ DATE USE OF A EXISTING BLDG. N DEMOL ❑ FINAL B y APPLICANT TEL (PRINT) Carl sberg Const. CONNO. _ ADDRESS 2800 28th St., Santa Monica, C PRESENT BUILDING ADDRESS LOCALITY MOVING TEL. t/ e 0 lir CONTRACTOR NO. {/ ,r ADDRESS REQUIRED HWY TOTAL SETBACK FROM EXIST. SET BACK YARD PROP LIF WIDTH SIDE P. L. x 0-d` 100 :Investigation $ , Y f�ermit Issuance Fee Fee Total Fee r /et4(�. 0 SEE REVERSE FOR EXPLANATORY LANGUAGE VALIDATION 2_C 64.0A 1-71 7,60 ®'. 71 7, 6 0 o 7,06-81 Signature of Applicant or Agent , / /Dote ©s