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Home My WebLink About4621A 0811A 0812AWORKERS' COMPENSATION DECLARATION I hereby affirm that I hove a certificate of consent to self Insure;, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lob. C.) Policy No.WQ80033111-Company Certified copy is hereby furnished. . Certified copy is filed with the county building inspec- tion department. Dots 7/2/84 Applicant Koppel Services Inc. 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. DateApplicant 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 287828 Lic. Class RI Contractor Koppel Services IBD.Date 7/2/84 I am exempt under Sec. B.BP.C. for this reason Signature OWNER -BUILDER DECLARATION. I hereby affirm that I am exempt from the Contractor's License Low 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 compen<-ation, 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 properly, am exclusively contracting - with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 1hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued 1Sec. 3097, Civ. C.). Lender's Name Far West Savings E Loan Mac Arthur Blvd. Lender's Address Mnypnrf- Reae6rCA 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 ab ntioned property for inspection rpo es j;x 9 nature of Applicant or Agent -Z Dote APPLICATION FOR BUILDING -PERMIT COUNTY OF LOS ANGELES • BUILDING AND SAFETY FOR APPLICANT TO FILL IN nuI aLDI rill BUILDINGDDRAera a Cluster For Bldg. #14.. LOCALITYA.B.BJ NEAREST CITY Masond Bar ZIP 91765 CROSS ST. NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT KongMAP BOOK PAGE PARCEL US ONE MAP D J [ TRACT BLOCK LOT NO. 3 NO. yi TELA - n SPECIAL OWNER Far Nest Savings C Loan NO.833-8383 I I CONDITIONS DISTRICT GROUP ITYPE I FIRE PROCESSED BY ADDRESS O —/ CONST ZONE CITY art Beach. CA ZIP STATISTICAL C1A55'1f KA^TION APT. ONDO. ARCHITECT ORNed Noltz C Assoc. - TEL 120ENGINEERNO.547-5679 CLASS NO. DWELL. UNITS ADDRESS 1823 E. 17th _ Santa Ana SEWER MAP CONTRACTOR Koppel Services Inc. TELNO.213/595-4871 BK. - PG, VALIDATION LIC. ADDRESS3703 Lona Beach Blvd. No.287828 VALUATION CLA 1; a4Cin SO. FT. N. OF NO. OF CHECK F 4 6 2 1 A SIZE STORIES FAMILIES ONE DESCRIPTION OF WORK NEW © S 26, % 7tv V R.. e 21 8) Car Garage ADD .. I .-71.40 ALTEEl FINAL DATE - %i0 e . • 7.1. 4 3RMAIRO USE OFEXISTING BLDG. DEMOL. - By A O 7. L0j nca iret.rr T11 7 L SEE REVERSE FOR EXPLANATORY LANGUAGE _ 1.60 CL Q U C O U i rn2 Os I 7 0 0O 7 T N O 11 0 O O n n tp a.n T 2_ O. O i nb O- V •' ., •`T .r f;`+• •• • k w 7- • ci '`_` w `... 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