HomeMy WebLinkAbout4622A 0813A 0814AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, ora certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy 11t CompanyP®
Certified copy is hereby furnished.
ElCertified copy is filed with the county building inspec-
tion department.
Dote 7/2/84 Applicant Koppel Services Tnr-
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, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
DataApplicant - .
NOTICE TO APPLICANT: If, after making this Certiftcote 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 Bl
Contractor Koppel Services Inc. Dote 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
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 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 -
on 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm that there is a construction lending agency for
the performance of the work for which this permit is issued
ISec. 3097, Civ. C.).
Lenders Name Far West Savin S E Loan
Mac Arthur DIV .
Lender's Address WaupartBeach, 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 the obove- enn ned property for Inspection purposes.
gnature of Applicant or Agent er.te
APPLICATION. FOR BUILDING PERMIT
COUNTY OF LOS ANGELES.... BUILDING AND SAFETY
OR APPLICANT TO FILL IN n DRSS
ING
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REssGara a Cluster For Bldg.20 LOCALITY .
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NEAREST
ZIP CROSS ST.
NO. OF BLDGS. ASSESSOR
OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
U E ZONE MAP O (i— } JTBLOCKLOTNO. 3 .: NO. O ••7
ER Far West Savings C Loan TEL. - NO,833-8383 cJp SPECIAL
CONDITIONS
DISTRICT GROUP TYPE FIRE PROCESSED BY
ESS 4001 Mac Arthur Blvd. r,,E393
CONST.
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ZONE
d3 nV frr'
ZIP
ITECTRd Holtz E Assoc. - TEL' 547-5679
STATISTICAL CLASSIFICATION APT. CONDO.
INEER NO. CLASS NO. /ALJ DWELL. UNITS
ESS 1823 E. 17th- Santa Ana CA SEWER MAP
TRACTORcpq L' N0. BK.- FG, VALIDATION
E3903 Lon Beach Blvd. nio.287826 VALUATION
cross L .lb'r8
FT NO. OF NO.OF18801 CHECK110. N/ASTORIESFAMILIES ONE
2(17`
f- 4 6 2 2 A
OF WORK NEW
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ADD
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REPAIR
DATE
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