HomeMy WebLinkAbout4605A 0821A 0822AWORKERS' COMPENSATION DECLARATION
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, Lab. C.)
Policy No.YPRDn771 11 company Xss c Turlemn, t
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date 7/2/84 Applicant_ Koppel Services Tnc.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
hundred dollars (EI00) 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.
Dote 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 . Uc. Class B1
ContractorKoppel Services Inc. Date 7/2/84
I 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):
1, 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 Cade).
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 Nest Savings E Loan
4001 Mac Arthur Blvd..
tender's Address Newport Beac , CA
I certify that 1 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 theupontheabtionedpropertyforInspectionforInspectionpurposes.
Signature of Applicant or AgentApplicantorAgent Date
APPLICATION FOR BUILDING PERMIT Il
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN noness .2 f
BUILDINC.z ardye Cluster Far Bldg. X21. ADDRESS LOCALITY-_
CITY Oiamand Bar ZIP 91765 NEARESTCROSSST.
NO. OF BLDGS. ASSESSOR
SIZE OF LOT NOW ON LOT Nnnp MAP BOOK PAGE PARCEL
TRACT 34831 BLOCK LOT NO.
USE ZONE
1
Op—
NOP
TEL: --
OWNER yings & Loan N0833-8383 L
SPECIAL
CONDITIONS
DISTRICT GROUP TYPE FIRE PROCESSED BY
ADDRESS coZONE
V 11YYYY// 19A/- CITY Newport Beath, CA ZIP92660
ARCHITECT OR TEL STATISTICAL CLASSIFICATION APT. CONDO.
ENGINEER Red Noltz C Assoc. NO.547-5679 - CLASSNO, !7-9 DWELL: UNITS I
ADDRESS 1823 E. 17th St - Santa Ana CA - SEWER MAP
CONTRACTORppppryleas TEL. NO. _ BK. - PG, VALIDATION
ADDRESS 3703 Lon Beach Blvd. NO.287828
CLASS
VALUATION
4CITYLoneBeach, CA B-1 s
SO. FT.NO. OF NO. OF CHECK
SIZE 1680 STORIES I FAMILIES NIA ONE h' 4, 7 4 6 Q 5 A
DESCRIPTION OF WORK NEW ®
S
4....21ADDpCarGaraae
ALTER
Detached Cl
FINAL
DATE /
7 1, 4 Q
USter REPAIR I
7- 1 U.r=sUSEOF
EXISTING BLDG. - ... .. DEMOL AFINAL
APPLICANT- -n__..____ •__ TEL.o,•Trnr- rn,. BY q% 07.1 9-84
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