HomeMy WebLinkAbout4602A 0797A 0798AWORKERS" COMPENSATION DELARATION
herebyaffirmthatI
have
a
certificatei
of consent to
1 .
insure, r a certificate of Workers Compensation insurance, APPLICATION FQR",BUILDING PERMIT
or&certified co thereof Sec. 3800, Lab: C.
WP80033111 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pollc No - Com n Assoc Indemnity -- - - - Y pa Y
Certified. copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department,
Dote ' 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 (5100) 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 Lows.
Date - 'Applicant
NOTICE TO APPLICANT: If; ofter'making this Certificate of
Exemption;youshould become' subject to the Workers' -`
Compensation provisions of the tabor 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 "tic. Class r 81'' -
Contractor' Koppel Services Incpole/94
I am exempt under Sec.
B.RP.C. for this reason
Date:
Signature - -- - -" --- - - - - -
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
taw 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- - - --
1 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 Far Mest Savings E Loan
4001 Mac Arthur Blvd...
Lender's Address lNewporl
1. 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
FOR APPLICANT TO FILL IN BUILDING
ADDRESS t GK..ra. /7 e t A1
BUILDINGADDREssGarage Cluster For Bld . #16
CITY Diamond BarZIP 91765 xaurr
NO. OF BLDGS: ..... ... ..... NEAREST ... __.
SIZE OF LOT NOW ON LOT None CROSS ST. .. -
ASSESSOR . -. __. ...
TRAET BNLOCKLOT O. MAP BOOK PAGE PARCEL
TEC.
OWNER Far Nest Savings 11 -Loan - No833-8383 - USE ZONE
pO X•
MAP O No.
ADDRESS 4001- Mac Arthur Blvd.- - ----- - - SPECIAL - - :- -
CONDITIONS '
CITY. _.ZIP
ARCHITECT R TEL.
ENGINEER IQed MD1tZ E Assoc. NO.547-5679 DISTRICT GROUP TYPE ---- CONST. FIRE.. Z7ONNE PROCESSED BY
ADDRESS 1823 E. 17t - Santa An CA l- 1J
TEL.
CONTRACTOR Koppel Services Inc. NO,213/595-4871 STATISTICAL CLASSIFICATION
CLASS NO. .. ..... ... .....DWELL. UNITS .
APT. NDO.
LIC. - _. - ...
ADDRESS 3703 Lon B Blvd. No.287828
LIC.
SEWER MAP
CIN CLASS
BK. - - - -
VALUATION_
VALIDATION
460 2.{i
Q. FT NO. OF NO, OFSIZE1260STORIES - 1 FAMILIES N/A CHECKONE
DESCRIPTION OF WORK -" - --_-' - - NEW ®
9 1' y • • i ' jADD
ALTER
oil)••
5 6 5 3
0.4aGh-d C11 Tip REPAIR f 20 v -. 56537u: Mt
USE OFEXISTING BLDG. DEMOL
ANTE !o
o 7, 1 9- 8 4APPLICANTTEL.
PRINT) Koppel Services Inc. No.213/595-4871
ADDRESS 3703 Lon Beach Blvd. Lon Beach CA FIH
BY -
C; 79 ?'f
PRESENTBUILDINGADDRESS n ' e • e ; -
2 6 CI 5' LOCALITY
MOVING - __ ..TEL.. ..
CONTRACTOR NO. e e i L. (i C i
REQUIRED YARD F1WY 101AL SETBACK FROM XIST..
SET BACK PROP. LINE WIDTH
FRONT
P. t.
SIDEP.L.
LDMA Rei. #
lin t 1
713S-3P.GFee S- -sG.r3 _-- Permit Fee -
d 0-3 vG ` Issuance Fee- -- -/0'3 .... LOMA P/C #
LDMA Perm. M - - - i1r. 1 '
Investigation Fee
TomI Fee . / --
upon the above -m ntioned property for inspection purposes.
7 0 f SEE REVERSE FOR EXPLANATORY LANGUAGE
SiK.1— of Applicant or Agent - .. pee
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