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WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, Bldg.26
or a certified copy thereof (Sec. 3800, Lob. C.) Units 86,87,88,89 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.�_ 54yCompony &`L S.Jc11TlE'S CO.
Certified copy is hereby furnished.
r.Il Certified copy is filed with the county building inspec-
uu tion department.
Date 411Z8 Applicant Carlsbe g 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.)
1 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.
Uconse Number 31.7237 Lic. Class B-1.
Contractor Carlsberg COnst". 4Z1.%85
ElI 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 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).
® 1, 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
JSec. 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.
Signature of Applicant or Agent Dale
MMMMIM
FOR APPLICANT TO FILL INd76
BUILDING
ADDRESS
e
BUILDING
ADDRESS 3030 La Paz ZaTleLOCALITY
CITY Diamond Bar ZIP 91CROSS
NEAREST
ST.
_
p� � NO. OF BLDGS.ASSESSOR
NMAP
SIZE OF LOT UbCIlV1S3.On NOW ON LOT
BOOK
PAGE
PARCEL
USE ZONE
MAP
TRACT
BLOCK
LOT NO,NO.
TEL.
SPECIAL
OWNER Carlsberg Const.CO. NO.
CONDITIONS __J -FIRE
2800 28th St.
DISTRICT
GROUP CONST, ZONE PROCESSED BY
TYPE
ADDRESS
CITY Santa Monica ZIP
-9/-
CLASSIFICATIONENGINEER
ARCHITECT OR TEL \STATISTICAL
Vito Cetta AIA
NO.CLASS
NO.
DWELL. UNITS
ADDRESS 1419 2nd St.Santa Monnica c-:a.yU4U.:
SEWER MAP
L. CONTRACTOR Carlsbercq COnst.C4E®, 0
BK. PG,
VALIDATION
ADDRESS 2800 28St. � NO. 31 2Z 37
VALUATION
CITY manta MfJnica _ CLASS LIC.B-1'
9 1
SQ. FT. NO. OF NO OF 4 CHECK �K
2
SIZE STORIES FAMILIES
a6.2a
4 . s @ . i_
DESCRIPTION OF WORK NEW �
Z
( a % �j Q
Wood Frame T wnhcdi es ADD
a 7 �' `� 0
ALTER []
FINAL
REPAIR Erl,
DATE
0 5, 0 6 r 8 5
USE OF DEMOL u
EXISTING BLDG.
FINAL
By
APPLICANT TE 0
PRINT) Carlsberg Const.CONO.
ADDRESS 2800 28th St.Santa Monlca,Ca.904PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
Annuccc
YARD
HWY
TOTALSETBACKFROM
EXIST.
PROP. LIN
WIDTH
PREQUIRED
Permil Fea
Issuance Fee
Investigation tee
Total Fee
�/+ i
SEE REVERSE FOR EXPLANATORY LANGUAGE
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