HomeMy WebLinkAbout3974AWORKERS' 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.WC1-21.954e4npany M] ssi:gn Ins,. CO.,
DCertified copy is hereby furnished.
ElCertified copy is filed with the county building inspec-
department.
Date '-Applicant Applicant ('xgljpng Conat CO.
CERTIFICATE OF EXEMPTION FROM WORK: E&
COMPENSATION INSURANCE
(This section need not be completed if the permit is fonone
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 317.237 Lic. Class Btl-
Contractor Carlsberg COnstte 9./2/82
ElI 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 9.0017
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
pon e above-mentione tq operty for inspection pur oseess..
Signature of Applicant or Agen D to
APPLIRC."'ATION FOR BUILDING PERMIT
C®U�lTY ®S NG LES BUILDING AND SAFETY
FOR APPLICANT TO FILL INd.CC!A
BUILDING
ADDRESS
BUILDING
ADDRESS
LOCALITY
CITYDiamond Bar CA ZIP 91765CROSS
NEAREST
On 10't NO. OF BLDGS.ASSESSOR
_
SIZE OF LOT NOW ON LOTMAP
BOOK
PAGE
PARCEL
TRACT �M,14534
BLOCK
LOT NO.USE
ZONE
MAP
NO.
TEL. (2�
SPECIAL
OWNER CarlsbergCOnst. Co. NO. 450
CONDITIONS
28aO 28th, Street
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
ADDRESS
COP
Zp ,
CITY Santa 'Monica CA ZIP 90405�
CLASSIFICATION
APT.
CONDO.
ARCHITECT OR TEL.STATISTICAL
ENGINEER asadena Design ASsa.. 7
CLASS NO. DWELL. UNITS
MMMMM
ADDRESS 1(TQ ( F. _ C »aani _ _ Pa saAP
SEWER MAP
CONTRACTOR Carlsberg COnSt. No. 4901��00
BK. PG, VALIDATION
LIC.
ADDRESS 280 .; 28th -Street No.317237
VALUATION
Santa 'MOniCa, CA, B.-1
CITY CLASS
$ 377,000
$
SQ. FT.
SIZE 9-,410_
NO. OF
ISTORIES 2
NO. OF
FAMILIES 5
CHECK
ONE;
DESCRIPTION OF WORK
NEW ®
wood fYlarge townhouses
ADD
ALTER
FINAL
,✓�
?r'J93 ;"�,,r.... X`�� ?'jj-"' fi.��....i �`t'a'•r.s,`
REPAIR
DATE
FINAL 22 37, 4 A
USE OF
EXISTING BLDG.
DEMOL
By #� ®� 2 8
APPLICANT Carlber Const. COTEL" 45 -- 0'
s
(PRINT) g Mo.
3 S 9, 8 4
ADDRESS 2800 28th. St., S.M: , CA 90405
'�
ffi s J 3 11 8 �jBUILDING
PRESENT
ADDRESS
1
r�(PI�L Q E%OCI®82
O(
LOCALITY
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
FRONT
P. L
SIDE
P. L.
P.C. Fee $., Permit Fee
igotion
Issuo
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE