HomeMy WebLinkAbout8633AWORKERS' 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 lWa thereof (Sec. 3800, Lab. C. )
®cyNo. 21,954—A Company miggiQyi lnS.—CO
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date 6Z29/81 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 70DD) 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 Const. Date 6/29/81
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
I w I 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
j < u on the above-mpxntioned pr perty V inspection purpos s.
I� /
Si nature of Applicant or Agent Dote
r• L h1 Ox a ; BUILDING
.-
IC ••
PERMIT
Type BUILDING AND SAFETY
�• ••• •
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS
LOCALITY
CITY Dl mond Bar CA ZIP 91765
NEAREST
CROSS ST.
�(
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
NO
TEL. 2j_3
1
SPECIAL
OWNER Car sber Const. Co. NO.
CONDITIONS
DISTRICT
GROUP TYPE FIRE PROCESSED BY
ADDRESS 2800 28th Street
CONST. r.-- ZO/NE
CITY Santa Monica CA ZIP 90405 s
ARCHITECT OR TEL.
STATISTICAL CLASSIFICATION APT. CONDO.
ENGINEER Pasadena Design
CLASS NO.
DWELL. UNITS
AUUKtJJ 1u4.L Z. careen az. vasaaena ua
JtwtK MAY
CONTRACTOR:
TEL, 23
NO.
BK. PG,
VALIDATION
ADDRESS 2800 28th
LIC.
Street No. 317237
VALUATION
863,3A
CITY
CLASS —
SQ. FT. NO. OF
SIZE 7,671 STORIES .
I NO. OF CHECK
2 FAMILIES 4 ONE,
i 7, C' 0
DESCRIPTION OF WORK
NEW ®
t�
o/
/ t7
). 7 12 8 0
wood frame townhouses ADD ❑
z 7
. ® 7 c Q Q 0 2,1
ALTER El
FINAL
REPAIR
DATE
0 7. 0 6.- 8 1
USE OF
EXISTING BLDG. N/A
DEMOL
FINAL
By
APPLICANT
(PRINT) CarlsbergConst.
TEL.
CO No.
ADDRESS 2800 28th
Street, S.M. , CA
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
TEL.
CONTRACTOR
NO.
ADDRESS
REQUIRED
SET BACK YARD HWY
TOTAL SETBACK FROM EXIST,
PROP. LINE WIDTH
FRONT
P.L.
SIDE
P.L.
P.C. Fee $
Perm'it Fe
o
Issuance Fee e3 _'� ��. o
Investigation Fee
.
Total Fee
/623 610
SEE REVERSE FOR EXPLANATORY LANGUAGE
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