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HomeMy WebLinkAbout8639AWORKERS' 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, �y thereof (Sec. 3800, Lab. C.) Policy No. 21 954,A. Company Mi ac )n InS r'O. ® Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Date 6/29181 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 ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this. permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 41 7237 Lic. Class _$-_ Contractor Carlsberg Const-Date 6/29181 1 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, tor 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 1 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 Cal i forpi a Lender's Address 550 S. Flower, L.A. , CA 90017 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 uv-, hke above-mentio� ` prope� for inspection yurposfs. Signature of Applicant or Ag$nr / I Date f APPLICATIU100"INBUILDING • • • FOR APPLICANT TO FILL IN ADDRESS t� t) �( �'+ �t �� :.h.� �;..✓ BUILDING ADDRESS LOCALITY CITY Diamond Bar CA ZIP 91765 NEAREST CROSS ST. { // one lot NO. OF BLDGS. ASSESSOR !l SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT BLOCK LOT NO: USE ZONE MAP ) } ,- NO. TEL. 213) SPECIAL OWNER NO. - CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS 2800 28th Street CONST. ZONE ��"9� �Yr CITY Santa Monica CA ZIP 904 5 OR TEL, 213f STATISTICAL CLASSIFICATION f APT. ENGINEER Pasadena Design Assoua — CLASS NO , DWELL. UNITS f 1CONDOIIIIIIIIIIIIIJARCHITECT ADDRESS 1_r SEWER MAP CONTRACTOR Carlsberg TEL. Const. NO. BK. PG„ VALIDATION ` 9 R ADDRESS 2800 28th Street No. 317237 VALUATION 2. CITY Santa Monica C CLASS _a $ 227 800 SQ. FT. NO, OF NO. OF CHECK 60600 SIZE 34$ STORIES 2 FAMILIES 4 ONE d6 DESCRIPTION OF WORK NEW $ r 9 ®' E' 9 6, O 0 ADD ® Z, j 07,06-81 ALTER ® FINAL REPAIR ® DATE USE OF EXISTING BLDG. DEMOL ® FINAL B y APPLICANT (PRINT) Carlsberg TEL. 213 Const. NO. _ ADDRESS 2800 28th St., Santa Monica, CA, PRESENT BUILDING d�c ADDRESS LOCALITY sry MOVING TEL. i CONTRACTOR NO. p ADDRESS REQUIRED SET BACK YARD HWY TOTAL SETBACK FROM EXIST. PROP. LINE WIDTH FRONT P.L. SIDE P.L. P.C. Fee $ q / PL>'. Permit Fee Issuance Fee ,• _`> Investigation Fee r Total Fee - SEE REVERSE FOR EXPLANATORY LANGUAGE r ©s