HomeMy WebLinkAbout8638AWORKERS' 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 W,py thereof (Sec. 3800, Lab. C.) Policy No, 21Q�a_Company MiSSion Ins, C X❑ Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Date 6/29/81 Applicant Carl -hpra Cnngt CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become'subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under, provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 31 7237 Lic. Class_$—]' Contractor Carlsberg Constaate 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 Co. 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. 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 proper for inspection p rpos 1 Signature of A plicant or A eM Date ¢ta ,� • • , 0, trio llfl=x n1 a— C0.VNTY OF L QS ANGELES BUILDING AND SAFETY • u.i.0 1 C 1J UII.L-CS 0 FOR APPLICANT TO FILL IN BUILDING t ADDRESS" BUILDING ADDRESS LOCALITY%-� 2 _ �Z�? fi G..,✓/ CITY D,iaMOnd Brazip gi NEAREST d �� CROSSST, i --�t_I Jf �. •. p-gat One 10t NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACTPM 14534 BLOCK LOT NO. 1 USE ZONE I AP NO. TEL. SPECIAL OWNER CarlsbergNo. _ --- -- j CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS 2800 28th Street - '� 1 CONST.., ZONE CITY Santa Monica, CA zip 90405 " ARCHITECT OR TEL. � 27.3) STATISTICAL CLASSIFICATIONJ APT, CONDO. ENGINEER _ 9 CASS NO. 0 2' DWELL. UNITS — ADDRESS CA SEWER MAP PG VALIDATION ��'�;63, 811 TEL..qena. CONTRACTOR CarlsbergBK. - uc. ADDRESS 2 2 NO. VALUATION CITY Santa Monica.A CLASS $ 291,700 ( �� [I. 9 6 �) SQ, FT. NO. OF NO. OF CHECK SIZE STORIES FAMILIES ONE t $ J ('3, 6 DESCRIPTION OF WORK NEW ® ADD El wood frame townhouses o %, 0 b- 8 1 FINAL ALTER ❑ REPAIR DATE FINAL By USE OF EXISTING BLDG, N A DEMOL APPLICANT (PRNT)Carl Sberg COnSt. CO.Np,450-' 68 2800 28th St., Santa Monica, C ADDRESS PRESENT BUILDING ADDRESS LOCALITY MOVING TEL. CONTRACTOR NO. G� Q f ®' ADDRESS YARD HWY TOTAL SETBACK FROM PROP. LINE EXIST. WIDTH ((�� �nI'r` 'jP V rmit eeIssuance Feen Fee Total Fee 7 `" �•-� /;�-/4. -!5v SEE REVERSE FOR EXPLANATORY LANGUAGE ©s