HomeMy WebLinkAbout3971AWORKERS' 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 copy thereof (Sec. 3800, Lab. C. )
PoticyNoWCTL 21954- mpany'Z? scion ins;, Co.
Certified copy is hereby furnished. -
OCertified copy is filed with the county building inspec-
tion department.
Date_�Z29ZK Applicant Canls;be q Const - Co,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundreddollars ($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 $ '1
Contractor Carlsberg Constoate 9/2/82
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).
1, 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 California
Lender's Address 550 S. Blower, B.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
%thbove-meniione property or inspection urp ses.
Signature of Applicant or Age .Do
APPLICATION FOR BUILDING PERMIT
•VV
• - ... . ` 1 ..ETY
G • • • - • 1•
FOR APPLICANT TO FILL IN
ADDRESS .. 4)4;,K,
BUILDING
ADDRESS
LOCALITY �>7
CITY Diamond, Bar, CA ZIP 91765
ST
CROSS ST.
- K
One lot NO. OF BLDGS.
ASSESSOR
SIZE OF LOT SiXbC11V1S NOW ON LOT
MAP BOOK
PAGE
PARCEL
TRACT �M ] 4534
BLOCK
LOT NO. 1 -
USE ZONE
MAP
NO. '
TEL 4 —
SPECIAL
OWNER Carlsberg Const. CO. NO 213 68
CONDITIONS
DISTRICT
GROUP TYPE FIRE PROCESSED BY
ADDRESS 2$00 2$th Street
CONST. ZSAJf
clrY Santa Monica CA zIP 90405�w
ARCHITECT O TEL. ((22ll )
OR_
STATISTICAL CLASSIFICATION APT. CONDO.
ENGINEER Desi n Ass�P• 7933�2 l
CLAS$ NO.
DWELL. UNITS
ADDRESS 1.041 E. Green
Si- _ PaGadpn
cm
SEWER MAP
CONTRACTOR Caxlsber
.,
TEL. 2 ]
Cons, NO.450
BK.PG
VALIDATION
LIC.
ADDRESS
NO,
VALUATION
Santa, Monica,
CA cLasS
B^1
234,00.0
CITY
$
SQ. FT. NO. OF
NO. OF
CHECK
SIZE 5 744 STORIES 2
FAMILIES 3
ONE
DESCRIPTION OF WORK
NEW
wood, fg.-ge townhouses
ADD ❑
ALTER ❑
FINAL
f�,� fii'�-'�i',9'��>
e,� �, i� �
REPAIR ®
DATE
2' 3 9 7, 1 A
USE OF
DEMOL
FINAL
# e • . s • 28
EXISTING BLDG.
By
APPLICANT TEL._03
(PRINT) Carlsberg Const. CgNo.
800
1® 2 3 1. S b
ADDRESS 280.0., 28th, St.
Santa Monica CA
9 • 23 1,360
PRESENT
BUILDING
L %J
0 9, 0 9- 8 2_
ADDRESS
LOCALITY
C
MOVING
TEL.
CONTRACTOR
NO.
ADDRESS
REQUIRED
SET BACK YARD HWY
TOTAL SETBACK FROM EXIST.
PROP. LINE WIDTH
SIDE
P.L.
P.C. Fee $ ;�,' / .-1' f.--;, IPermit Fee
Investigation Fee
Total
SEE REVERSE FOR EXPLANATORY LANGUAGE
0