HomeMy WebLinkAbout8634AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certifie,edj thereof (Sec. 3800, Lab. C. )
Policy No.9] 91 4_A Company Mi sSinn Tnc_ (n,
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
sous 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 COUSt.Dafe��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 Bank of California
Lender's Address 550 S. Flower, L.A. CA 90017
1 certify that 1 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 the abovegmentioned ropyertyftfr inspection p rpose .
1
ignature of Applicant or Agent Dote
CQUNTY OF LOS ANGELES BUILDING AND SAFETY
R1(1rr `Tune, Q TTnii-c A7 AP Z AQ
IN III "i
BUILDING rJ,
ADDRESS
FOR APPLICANT TO FILL IN
BUILDING
1 j
ADDRESS
LOCALITY
NEARE
CITY ZIP
CROSSS T. LL
One lot NO. OF BLDGS.
ASSESSOR !'
SIZE OF LOT NOW ON LOT
MAP BOOK
PAGE
PARCEL
TRACT PM 14534
BLOCK
LOT NO. 1
USE ZONE
-: /
k--
MAP _ /
NO. ��� `"
TEL.
OWNER Carlsberg Const. CO. NOAr
SPECIAL
CONDITIONS
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
ADDRESS 2800 28th Street
r
CONST -
ZONE
CITY Santa Monica CA zip 90405
ARCHITECT OR TEL. (213)
STATISTICAL CLASSIFICATION APT. CONDO,
�
ENGINEER. PasadenaDell n Assoc
CLASS NO � �- DWELL. UNITS G`
SEWER MAP
BK. PG, VALID#T OLD, 4 A
ADDRESS 1041 E. Green St., Pasadena CA
TEL
CONTRACTOR Carlsberg Const. NO.
LIC.
ADDRESS 2800 28th Street NO. 317237
VALUATION; 6 & 2 3
UC.
CITY Santa Mon ca CA CLASS B-1
$ 178,100 ( 5 7 8. 4 0
SQ. FT.
NO. OF
NO. OF
CHECK
SIZE 5 744
STORIES 2
FAMILIES 3
ONE
O%d,QC
$ 7 4` q, f� 0s
DESCRIPTION OF WORK
NEW ®
wood frame townhouses
ADD ❑
FINAL
ALTER ❑
REPAIR ®
DATE
FINAL
By
USE OF
EXISTING BLDG. N A
DEMOL ❑
APPLICANT TEL ]
3
(PRINT) Carlsberg Const. CONO.
—
ADDRESS 2800 28th Street, Santa Monica,
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
�({
ADDRESS
REQUIRED
YARD
HWY
TOTAL SETBACK FROM
EXIST.
SET BACK
PROP. LINE
WIDTH
FRONT
P.L.
SIDE
P.L.
P.C. Fee $ t'1 Perm ee���
.•
Issuance Fee
Investigation Fee
I' 4
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE