HomeMy WebLinkAbout3973AWORKERS' 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 No,WC-1.219547CAf„panyP_4iS5i9n Z'ns,. Co
® Certified copy is hereby furnished..
Certified copy is filed with the county building inspec-
tion department.
Date 6/2g/8- Applicant Ca3;Jsbpi2d 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 $;-1
Contractor Car7,sbe3;g . Const.pate 9/2182
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 rr(y 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 Calitor�n a
Lender's Address 550. S•. Blower; T,.A. CA -9.0.0.17'
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
upon the above -mention d property' or inspection pur oses.
nature of Applicant or Age G D to
rJi
Blda. Tvbe 5, ®UtNTY7�F--P 'f EI S80 BUILDING AND SAFETY
TO FILL IN
BUILDING
ADDRESS'✓�iit
BUILDING
-
TAPPLICANT
ADDRESS
LOCALITY
CITYjDTaIIlOnCI ZIP 9,17657
NEAREST
CROSSST.NO.
OF BLDGS.
SIZE OF LOT E;u NOW ON LOT none
ASSESSOR
MAP BOOK
I PAGE
PARCEL
TRACT PM 3.4534
BLOCK
LOT NO. 1
USE ZONE
a_ 1
NO,
TEL. 1�
SPECIAL
OWNER -j. NO -,
CONDITIONS
2800 28th. Street
DISTRICT
GROUP
TYPE
CON ST....
FIRE
ZONE
PROCESSED BY
ADDRESS
CITY Santa 'Monica; CA ZIP 90405
ARCHITECT OR TEL. r22 33))
STATISTICAL CLASSIFICATION APT. CONDO.
ENGINEER Pasadena Design n Assala.. 79319201
CLASS NO. DWELL. UNITS
SEWER MAP
BK. PG, VALIDATION
$ 39.0000
ADDRESS 20-41 T;' . Q_iFeen ' St. Pasadena CA
TEL 1
CONTRACTOR CarlsbergCon St. CWG.
ADDRESS 280.0: 28th Street "c. 317237
NO.VALUATION
CITY Santa 'MOnuC.
C1. CLASS B- l
SQ. F9 551
NO, OF 2
NO. OF 5
I
CHECK
SIZE
STORIES
FAMILIES
ONE
$
o
FINAL z J 9 %,J A
DESCRIPTION OF WORK
NEW
wOOcl frame townhouses,
ADD ®
ALTER ®
REPAIR
DATE ®® 2 8
FINAL
By
®; 3 4 It. b Lt
0 9, 0 9 -6 8 2
USE OF
EXISTING BLDG.
DEMOL ®
APPLICANT TEL
(PRINT) Car7.sbergg Constr. .. CPG. - 800
ADDRESS 280.0. 28th, St., S.M. CA 90405
PRESENT
BUILDING
ADDRESS
� tQ
LOCALITY
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP, LINE
EXIST,
WIDTH
FRONT
P.L.
SIDE
P.L.
r 44 k,,$''q
P.C. Fee $ 11
Permit Fee
Issuance Fee
Investigation Fee
-
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
2