HomeMy WebLinkAbout7751AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.-J-5-53546 Company HCAM Insurance CO.
❑ Certified copy is hereby furnished.
®Certified copy is filed with the county building inspec-
tion department.
Date 1/28/85 Applicant Carlsberg 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 317237 Lic. Class B-1
Contractor Carlsberg Const.Date 1.28/85
❑ 1 am exempt under Sec.
B,&P.C, for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
1 hereby off irm 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 sole (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
Lender's Address
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 -mentioned property for inspection purposes.
1 I I PERMIT
B1dg.No.20 rnttwTV nr ins: Awr-'Clrt ntntntwr_ Awn CArCTV
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS 3015 La Paz Lane
LOCALITY
CITYpiamond Bar ZIP 91765
NEAREST
CROSS ST,
NQ. OF BLDGS.
ASSESSOR
SIZE OF LOT One Lot 1 11W11011DT One
MAP BOOK
PAGE
PARCEL
TRACT 14534
BLOCK
LOT NO.
USE ZONE
OP
TEL.
OWNER Carlsberg Const.Co. NOAg'0480Q_
SPECIAL
CONDITIONS
DISTRICT GROUP TYPE
FIRE PROCESSED BY
ADDRESS
CONST.
ZONE
CITY Smta Monica ZIP 90405
ARCHITECT OR TEL.
STATISTICAL CLASSIFICATION
APT. CONDO.
ENGINEER NO.41
CLASS NO. DWELL. UNITS
ADDRESS 1419 2nd St. Santa Monica 90401
SEWER MAP
TEL.
CONTRACTORCarlsberg Const.COyO.
BK PG
VAL, IDATION
LIC.
ADDRESS No.317237
VALUATION
7 7 5, l A
CITY Santa Monica 90405 CLASS B-1
$ 299120
SQ. FT. NO. OF NO. OF CHECK
4
# s • , 4 2 3
SIZE $ STORIES 2 FAMILIES ONE
$
IA96263
DESCRIPTION OF WORK NEW
ADD ❑
�,9626J�
ALTER ❑
FINAL
0 1 2 9- 8 5
REPAIR ❑
DATE
USE OF DEMOL ❑
EXISTING BLDG. N A
FINAL
By
_
APPLICANT(PRINT) Carlsberg Const.CO • NO.
ADDRESS JQ i8th St. Santa Monica 90405
BUILDING���E-.,'17��
i
ADDRESS
LOCALITY
MOVING TEL,
CONTRACTOR NO.
ADDRESS
REQUIRED TOTAL SETBACK FROM EXIST,
SET BACK YARD HWY PROP. LINE WIDTH
hNT,$i
PermitFeea
i✓- �3
Issuance Fee
Total Fee
u
SEE REVERSE FOR 'cXPLANATORY LANGUAGE ILI
L
rr
Signature of Applicant or Agent Date
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