HomeMy WebLinkAbout3975AWORKERS' 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 NVS1=21954-1�ompony Mission Ins. Co.
aCertified copy is hereby, furnished.
Certified copy is filed with the county building inspec-
El department.
Dale 6/29/81 Applicant CatW; e27g 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, 1 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
Contractor Carl gberg . Cons.t;.Dat, 9 /2/82
❑ 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):
1, 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. E'loWe,3Ti-A. CA 90-017
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
upa e abo e-mentioned roperI f I,inspection urpo es.
Signature of Applicant or Agent Dat
BUILDINGAPPLICATION F%0R
Bldg. Type 17, C&R17 ��S M��LZES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDR s
NG
SS
LOCALITY _ - "�z A
Diamond Bar CA ZIP 91765
NEAREST l'
CROSS ST.
og • Q'42.S , NO. OF BLDGS.
ASSESSOR
F LOT NOW ON LOT none
MAP BOOK
PAGE
PARCEL
PM ] 4534
BLOCK
LOT NO,
USE ZONE
&
MAP 6
"r
TEL 2ll33
I
SPECIAL
R Carlsber Const. Co. NcA -b8 0
CONDITIONS
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
SS t'
CONST
ZONE
Santa ,Monioa�, CA ZIP 90.4"05
TECT OR TEL. l
STATISTICAL CLASSIFICATION APTEER
pasac1enA Desi n Assoc.. 7 �-01
CLASS NO.DWELL. UNITSSS
1041' 4• Green St.{ Pasadena, CA
SEWER MAP
BK. PG,
VALUATION
282 000'
TEL.VALIDATION
ACTOR arlSberg QOnS, t . CO NQ45 Q
ADDRESS 280,0 28th, Street No. 317237
Santa 'Monica CLASS
CITY
$ ,
SQ. FT
71058
NO, OF
2
NO. OF
4
CHECK
SIZE
STORIES
FAMILIES
ONE
397.5A
DESCRIPTION OF WORK
NEW
Wood fran)e toWnl1g4ses
ADD ❑
ALTER F]
:E',a`a �� s') (2i ' A_, tJ t'_r7 610',e
REPAIR ElDA
EFINAL 6 9 - 2 8
FINAL I® 269.76
By
USE OF
EXISTING BLDG. N/A
DEMOL ❑
APP(PRICANT TEL. -
Carlsberg ConSt. Co 45 - 96 0
NT) NO.
269,76c]
0 9, 0 9 --'8 2
ADDRESS 280"0" 28th, St. S'.M. CA 90405
PRESENT
BUILDING
ADDRESS
1/'��
C�
LOCALITY
3
MOVING TEL.
CONTRACTOR NO,
1
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
FRONT
P. L.
SIDE
P.L.
P.C. Fee $ 7,,
Permit Fee
Issuance Fee
Investigation Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
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