HomeMy WebLinkAbout9694AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, Bld4 , 28 L 'ON FOR BUILDING RM i T
or a certified copy thereof (Sec. 3800, Lab. C. )
PollcyNo. PM1553546bmpany Fred S.JaMes &Co.Units 94,95,96,97 COUNTY OF LC?S ANGELES BUILDING AND SAFETY
® Certified copy is hereby furnished.
®Certified copy is filed with the county building inspec-
tion department.
Date 4/1/85 AppllcantCc_tr1sbM 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 317217 Lic. Class R-1
Contractor Carl sbera C hnst_0c to Q /1 /R_9
® I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
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 Cade):
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),
E3I, 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
ISec. 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.
FOR APPLICANT TO FILL INJCLASS
BUILDING
RESS
3050 La Paz Lane
LITY
lawnd Bar ZIP 9SS
REST
ST.
QjJe Lot NO. OF BLDGS.
SSOR
OT NOW ON LOT
BOOK
PAGE
PARCEL
Ml 4534
FENGINEER
BLOCK LOT NNO.
ZONE
MAP
Carlsberg COnst.CO. NO. TEL
SPECIAL
CONDITIONS
2800 28th St.STRICT
GROUP
TYPE
FIRE
PROCESSED BY
CONST.
ZONE
nta Monica ZIP
T OR TEL.ISTICAL
CLASSIFICATION
APT.
CONDO.
R Vito Cetta. AM NO.ASS
NO.
DWELL. UNITS —f
AVVKCJJ J-41yG(
CU1L.d 1"UJ111C:ci 1.c1.7V�i
JCWCK MAY
CONTRACTOR Carlsberg Const.G�,E��213)
BK. PG,
VALIDATION
ADDRESS 2800 28th St.
rio 317237
—
VALUATION
CITY Santa Monica
CLASS B-1
s
222,000
SIZJEFT�STORIES 2
HECK
AMILLIIES 4 CHE
P 9 6 9.4 A
DESCRIPTION OF WORK
NEW ®
S
• • • •
# 23
ADD ®
1- 8 9 1, 2 3
ALTER lJ
FINAL
DATE
® • 8 91,23
REPAIR
OF
EXISTING BLDG. Al A
DEUSE
MOL - ]
FINAL
C
0 `1 Q 6 — 8 5
APPLICANT
TEL. � 213
BY
PRINT
O,
ADDREss 2800 2�St,Santa
MOnica,Ca.904
010.
PRESENT
BUILDING
ADDRESS
MOVING •TEL.
AnnRFSS
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTHPermit
FREQUIRED
Fee
23
Issuance Fee
ee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
0
EM
Signature of Applicant or Agent Date
