HomeMy WebLinkAbout4620A 0817A 0818AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure,
it
a certificate of Workers' Compensation Insurance,
or a certfied copy thereof (Sec. 3800, Lab. C.)
Policy No.NP80033111 Company Aeenr_ Tndoonity.
Certified copy is hereby furnished.
Certified copy is filed with the county building Inspec-
tion department.
Date 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.
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
Prafessions Code, and my license is in full force and effect.
License Number 287828 Lic. Class B1
Contractor Koppel Services Int.Dote 7/2/84
ClI 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
Sec. 3097, Civ. C.).
Lender's Name Far Nest Say2,S E Loan
4001 Mac Arthur 81vd.
Lender's Address_ Beaeh, 6A
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 theupontheobonedpropertyforinspectionforinspectionpurposes.
f
gnoture of Applicant or Agent to
APPLICATION- FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN ADDRESS t/%
ADDRESSGarage Cluster For Bldg. //17Q
LOCALITY - _. r/J .
CITY Diamond Bar ZIP 91765 CRROSSST.
NO. OF BLDGS. ASSESSOR
SIZE OF LOT NOW ON LOT Mono MAP BOOK PAGE PARCEL
TRACT BLOCK LOT NO.
US ONE
3 -
MAP ONO. 34/
OWNER Far Nest Savings E Loan TEL: - NO.833-8383 7ZL SPECIAL
CONDITIONS
ADDREss 4001 Mac Arthur Bl
DISTRICT GROUP TYPECONST.
R
FIRE PROCESSED BV
ZONE
D I , lIIICITYNewportBeachCAZIP
ARCNITECf
Molts C Assoc. ---
92660
TEL. STATISTICAL CLASSIFICATION APT. "
7
ENGINEER ed No.547-5679 CLASS NO. 210 DWELL UNITS
ADDRESS SEWER MAP
CONTRACTOR Ka el Services Inc. TEL. No. 213 595-4671 BK. PG - VALIDATION
ADDRESS Long Beach, CA No. 287828 VALUATION
CITY Long Beach CA ITC. CLASS 8-1
SO. FT. NO. OF NO. OF
SIZE 1680 STORIES 1 FAMILIES
CHECK
NIA
ONEi0 4 6 2 0 A
DESCRIPTION OF WORK - NEW ®
l')
7
f /
y / v V 2 1 -
8) Cat Garage ADD 0 r • -71,40
Detached ClusterREPAIR
ALTER E] FINAL
DATE % 1..3 S 7 1.405
USE OF
EXISTING BLDG. DEMOL EJFIFINAL o 7. 1 9.— 8 4
APPLICANT TEL. n o
SEE REVERSE FOR EXPLANATORY LANGUAGE
s
1217—£,11.
011.
1217—11.
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