HomeMy WebLinkAbout3972AWORKERS' 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. )
Policy Nd^?CI-219,54-Company 'Mis,sion Ins. Co
® Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date 6/29/81Applicant CarlsberSj 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 Cons,t-Date 924(t82
❑ 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):
ElI, 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
I certify that I have read this application and state that the
above information is correct. ( agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives o this County to enter
up n th above -mentioned p operty fo inspection ' urp ses.
G
nature of Applicant or Agent Dale
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LM
COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
BUILDING
ADDRESS
FOR APPLICANT TO FILL IN
BUILDING
f�
z
ADDRESS
LOCALITY lVe e' rw ,
NEAREST
CITY ZIP
CROSS ST.
wNO. OF BLDGS.
ASSESSOR
SIZE OF LOY41vision NOW ON LOT none
MAP BOOK PAGE
PARCEL
Pjvj 4 4
BLOCK LOT NO.
USE ZONE
��``
L_�NDITIONS
.TEL.
Const. CO.NO 4 — OO
FMAPTRACT
ECIALowNERCalsberg
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
ADDRESS 2800 28th Street
61
JSanta
.� !
CONST'
ZONE,
-°
Monica, CA 90405
CITY ZIP
TEL
STATISTICAL CLASSIFICATION APT. CONDO.
ARCHITECT O� g 7g3-9201
ENGINEER as,aclena Des: n Ass /
CLASS NO. DWELL. UNITS
SEWER MAP
BK. PG, VALIDATION
ADDRESS n' t Pasadena CA
Carlsber COnst. TEL. :��3 800
CONTRACTOR � NO.
LIC.
ADDRESS NO. 31723
VALUATION
312 , 000
$
CITY Santa 'Monica L CA LIC. B-1
SQ. FT.
SIZE 7,671
NO. OF
ISTORlEs 2
NO. OF
FAMILIES 4
CHECK
ONE
DESCRIPTION OF WORK
NEW
FINAL
wood frame townhous@s
ADD
ALTER
REPAIR ❑
DATE
FINAL
_
By 9 7. 2 A -
28
USE OF
EXISTING BLDG. N 4A
DEMOL a
APPLICANT TEL
(PRINT)Carlsberg COnst. CO NO.4 6—] 4 00
ADDRESS 280.0. 28th St. S.'M. CA 90405
®2 8,0
PRESENT
BUILDING
ADDRESS
6�5 2 8.8, 0 0 v
LOCALITYkADDRE
0 g 0 9 �.. 8 2
TEL>
CTOR NO.
S
ED
CK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
T
$Permit Fee
Issuance Fee
tion Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
100