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HomeMy WebLinkAbout8635AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compenstion Insurance, or a certifieded thereof (Sec. 3800, Lab. C. ) Policy No. 219a4-A Company Mi_ iop IpcP.—(gyp. Certified copy is hereby furnished. ❑Certified copy is filed with the county building inspec- tion department. Date 6/29/81 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 ConstpatCwo. 6/29j87, ❑ 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 Bank of Cal-i forni 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 ao�for inspection p rpos s. ,11 Signature of Applicant or Age Dote ' APPLICATION FOR BUILDING PERMIT 'D 1 A- mi ti rf;RYNTY,OF , 9S 1 fgGEL;� BUILDING AND SAFETY FOR APPLICANT TO FILL IN ADDRESS BUILDING ADDRESS LOCALITY !-t r- f� NEAREST / 1 CITY Diamond Bar, -CA zip 91765 CROSS one lot NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW.ON LOT MAP BOOK PAGE PARCEL 34. USE ZONE MAP OCI TRACT F4r-M— BLOCK LOT NO. 1 NO. TEL. ) SPECIAL OWNER NO. CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS 2800 28th Street CONST ZONE //,) /t f .4 CITY Santa Monica, CA ZIP 90405 ARCHITECT OR TEL.. 213 STATISTICAL CLASSIFICATION APT. �, / 1. CONDO. ENGINEER Pasadena,' Desi n AsS00. 7,93-9 01 CLASS NO. (t % t: DWELL. UNITS ADDRESS LU41 B. Green S'C. rasaaena L, StwER MAP CONTRACTOR Carlsberg Const. .450-6800 BK. PG, tic. ADDRESS NO. VALUATION LIC, CITY Santa Monica, CA CLASS B_1 $ 211,000 SQ. FT. NO, OF NO. OF CHECK SIZE $O$ STORIES 2 FAMILIES 4 ONE NEW DESCRIPTION OF WORK A wood frame townhouses ADD ❑ ALTER ❑ FINAL REPAIR ® DATE USE OF DEMOL ❑ FINAL EXISTING BLDG. N/A By APPLICANT TEL (PRINT) Carlsberg Const. CO DO, ADDRESS 2800 28th Street, Santa Monica, A PRESENT be BUILDING ADDRESS" LOCALITY MOVING TEL. CONTRACTOR NO, ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. SET BACK YARD HWY PROP. LINE WIDTH SIDE P. L. t ` S'� P.C. Fee $ Vet"\ 1 . t(�l� Permit Fee t r' —7'' �' 1 Issuance Fee ;r •`� t-'� Investigation Fee Total Fee V.; - q 5_J, 4;,o SEE REVERSE FOR EXPLANATORY LANGUAGE N i 86.c;A 23 1-657.60 e657,60 0 7.06-8,1 �S ©s