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HomeMy WebLinkAbout8636AWORKERS' 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 c¢p6,thereof (Sec. 3800, Lab. C.) Policy No. 21 c3S4 —A Company M1SS1nn Iris CO. ® Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Date 612A1 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 117237 Lic. Class B-1 Contractor Carlsberg COnStDate _6�r2/B1 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, cim 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 1 forn9 a Lender's Address 550 S. Flower, 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 representatives of this County to enter upon thp above,-mentionel prope ty for inspection purpo es. gnature of App scant or Ag nl Dote ie } APPLICATION Bldg. Type 2A, COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESSi�-+'z :� 1- 9 r BUILDING ADDRESS LOCALITY /_.,, NEAREST CITY ZIP CROSS ST: J One to NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACTPM 14534 1 BLOCK LOT NO. 1 USE ZONE +_- --/E-! MAP t3 .TEL. (213) SPECIAL OWNER Carlsberg COriSt. CO. NO. CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS 2800 28th Street CONST,_../> ZONE CITY Santa Monica CA ZIP 90405 STATISTICAL CLASSIFICATION APT. ICONDO:. ARCHITECT OR TEL. ENGINEER > CLASS NO. ("'DWELL.UNITS T SEWER MAP BK. PG, VALIDATION ADDRESS TEL, 213) CONTRACTORCarlsber COnst. NO. - LIC. ADDRESS 2800 28th Street. No.317237 VALUATION ¢,' �.� �3 CITY Santa Monica CA CLASS B-1 $ 226,400 ( - 6 O �. 6 0 FT. NO. OF CHECK SQ. SIZE 7 303 STORIES 2 NO. OF FAMILIES 4 ONE $a09.3,60C, [� DESCRIPTION OF WORK NEW 4�4t r �/ 3�0 o 7, 0 6 - 8.1 ADD El wood frame townhouses FINAL ALTER REPAIR ❑ DATE FINAL By USE OF EXISTING BLDG. N A DEMOL APPLICANT TEL(213 PRINT) Carlsber Const. CO -NO. 4_ { ADDRESS 2800 28th Street., S.M. , CA PRESENT BUILDING ADDRESS y U /] W LOCALITY MOVING TEL. CONTRACTOR NO. ADDRESS REQUIRED SET BACK YARD HWY TOTAL SETBACK FROM PROP. LINE EXIST. WIDTH FRONT P.L. SIDE P.L. t. /�l�. P.C, Fee $ .l,-0 Permit Fee + Issuance Fee Investigation Fee Total fee / q/t.:;o SEE REVERSE FOR EXPLANATORY LANGUAGE ©i