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HomeMy WebLinkAbout8637AWORKERS' 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 thereof (Sec. 3800, Lab. C. ) , Policy No, 93 9S —Aw _Company Mi S2i-op. To. Certified, copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Date 61/29/81 Applicant C Arl sberg 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 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number '4172g7 Lic. Class B-1 ContractorCarlsberg Const. Date 61/2Pf/R1 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 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 upon the above -mentioned roeerty f r inspection urpos s. Signature of A p p I cant or Agent Date 1 .;r �� A� • �;, r #, i- Bldcr. Tvpe 17 , >TnIVNT59®F �RS �YGI L Z 6UILDING. AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING If ADDRESS LOCALITY NEAREST f' CITY Diamond Bar, CA ZIP 91765 CROSS ST. a" �� �7 i !� s .e.e „�;t ✓' One lot NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT BLOCK LOT NO. J USE ZONE L, MAP NO. j t1 ✓ =J '7 OWNER Carlsberg O stCo.NO• CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS 2800 28-th' Street / CONST..__.._- ZONE . CITY Santa Monica CA ZIP 90405 ARCHITECT OR TEL. (213 STATISTICAL CLASSIFICATION APT. CONDO. ENGINEER Pasadena De CLASS NO L' f'.r DWELL. UNITS SEWER MAP 8K. PG, ' VALIDATION ADDRESS 1041 E. Green St. Pasadena CA TEL, (213 ) CONTRACTOR Carl,sbex Construckion . LIC. ADDRESS 2800 28th Street NO. 3172 VALUATION 3 86 A CITY Santa Monica CA CLASS B-1 $ 218,800 `r `� SQ. FT. NO. OF NO. OF CHECK SIZE 7 058 STORIES 2 FAMILIES 4 ONE , 7 �7 3 to ' 71 "' ' FINAL 1 6 7 0 �: 6 7 4, 4.0 DESCRIPTION OF WORK NEW ADDR wood frame townhouses REPAIR ® DATE FINAL B y 00 6 :. 8 1 USE OF EXISTING BLDG, DEMOL APPLICANT TEL. (PRINT) Carlsberg Const. Cow. 50-6800 — ADDRESS 2800 28th St., Santa Monica, CA PRESENT BUILDING ADDRESS LOCALITY MOVING TEL. CONTRACTOR NO. ADDRESS REQUIRED SET BACK YARD HWY TOTAL SETBACK FROM PROP. LINE EXIST. WIDTH FRONT P. L, SIDE P.L. CIA -7 -V P.C. Fee $ Permit ee - ,� Issuance Fee y/'' >,u% Investigation Fee t Total Fee SEE REVERSE FOR EXPLANATORY LANGUAGE ©s