HomeMy WebLinkAbout3976AWORKERS' 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 .NWC1--2195.4-Aompany 4is5i:on I'ns. Co.
®. Certified copy is hereby" furnished.
Certified copy is filed with the county building inspec-
tio
n department.
Date 6129�81 Applicant Canlsb jx,q 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' CompensationLaws.
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 B-1
Contractor Carlsberg Const.Date 9/2182 .
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):
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 Calf fo.T.tn a
Lender's Address 550. S, F+ oW6.r L.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
upon t e clbo\�e-mentionej roperty f inspection p4irposks.
ignature of Applicant or Agent Dot
COUNTY �F 11.0 �►NGELES BUILDING AND SAFETY
RIc1rr_ Tvna. 11 _ TTnit_ C1. 9
FOR APPLICANT TO FILL IN
ADDREssa,.�r?�
y�
BUILDING
ADDRESS
LOCALITY?
NEAREST
CITY ZIP
CROSS ST.
NO. OF BLDGS.
ASSESSOR
Sjl ql 1SlOn
SIZE OF LOT NOW ON LOT
none
MAP BOOK
PAGE
PARCEL
TRACTPM 14534
BLOCK LOT NO.
1
USE ZONE
MAP
NO.
TEL.
SPECIAL
OWNER NO.
j
CONDITIONS
ADDRESS 280D: 281;h, Stteeet
DISTRICT GROUP
TYPE FIRE PROCESSED BY
CONST. ZONE .
CITY Santa MOnida ZIP 9.0.405
STATISTICAL CLASSIFICATION
APT. CONDO.
ARCHITECT OR TEL.
3
19
ENGINEER D
CLASS NO.
DWELL. UNITS
ADDRESS 3 0-4� �i'• ?peen St, p4!54dena , CA
SEWER MAP
TEL.
CONTRACTOR Carlabe]? COnst. CaQ.
1
4 �-ta 0.0
BK. PG,
VALIDATION
280-0- 28t}1 St • CA LIC.
ADDRESS NO.
VALUATION
Santa 'Monica CA CLASS
B-1
$ 156,000
CITY
SQ. FT. NO. OF NO, OF
SIZE 3 780- STORIES 2 FAMILIES 2
CHECK
ONE
DESCRIPTION OF WORK
NEW
$
WOo4 FY'aIC)e `t'oWmbpijpes
ADD
"v) 9 7, 6 A
ALTER
FINAL
>„ � s� ! ,"y' � v, ,, e J y r e
. REPAIR a
DATE
s.r a o 0 o 2 8
USE OF
EXISTING BLDG.
DEMOL
FINAL
By
, 0 17280
APPLICANT TEL.
(PRINT) Carlsor Const.. Coro,
4 0- 00'
�'e 1 /2,80�
ADDRESS 280.0,' 28th, St., S.M. CA
90405
0 9, 0 q -•8 2
PRESENT
MENEM
BUILDING
ADDRESS
n
LOCALITY
(✓/ Iv C
MOVING TEL.
C1 J
CONTRACTOR NO.
q i
EXIST.
YARD HWYWIDTH
FDDRE
� �T ±Fee
Investigation Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
Eon