HomeMy WebLinkAbout4600A 0803A 0804AWORKERS' 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, Lob. C.)
Policy No.MP80033111 Company Assoc. Indemnity
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion depanment.
Date 7/2/84 Applicant Koppel Services Inc.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Thls 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, 1 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 287828 Lie. Class 01
Contractor Koppel Services Inc. Dote 7/2/84
am exempt under Sec.
B.BP.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).
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
See. 3097, Civ. C.).
Lender's Name Fat West Savings C Loan
4001 Mac Arthur T1vJ.
Lender's Address Newport Reachr DA
I certify that I hove read this application and state that the
above information is correct. I agree to comply with all County
ordinances end State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the abov -mentioned property for Ins/
Dcit.
urposes.
Signature of Applicant or Agent
APPLICATION- FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
SEE REVERSE FOR EXPLANATORY LANGUAGE
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BUILDING
BUILDING
ADDREssGarage Cluster For Bldg. #13....... LOCALITY ..
NEAREST
CRY Diamond Bar ZIP 91765 CROSS ST.
NO. OF BLDGS. ASSESSOR
SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
34831 BLOCK NO.
USE Z NE MAP G
NO. OTRACTLOT
SPECIAL _ TEL.'
OWNER NO. _ Z CONDITIONS
DISTRICT GROUP TYPE FIRE PROCESSED BY
ADDREss4001 Mac Arthur Blvd. CONST ZONEZONE_
CITY ZIP
STATISTICAL CLASSIFICATION APT, CO
ARCHITECT OR TEL
ENGINEER NO. CLASS NO. DWELL UNITS
ADDRESS SEWER MAP
TEL.
CONTRACTOR K 1 Services Inc. No. 213 595-4871 BK. PG. VALIDATION
LIC.
ADDRESS N0. VALUATION - z4600ALIC.
CITY Lan Beach CA CLASS B-1
111• • • • 250. FT.NO. OF NO. OF CHECK
SIZE 1260 STORIES 1 FAMINES M A ONE
s lJ cra 1-5653
NEW 119DESCRIPTIONOFWORK-
5653'
6 Car Gara a
ADD C]•
ALTER FINAL
DATE •
07.l 8 (! C: L 7•. i v
USE OF
DEMOL - FINA 1: • e e • 23
EXISTING BLDG. - -
APPLICANT TFL
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