HomeMy WebLinkAbout4623A 0815A 0816AWORKERS' COMPENSATION DECLARATION
1 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 NoWP80033111 Company Assoc, Indemnity
OCertified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Dale 7/9/94 Applicant Koppel 4eru; a TUC_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
hundred dollars ($I00) 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 monner
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 Lic. Class B1
ContractorKoppel Services Inc. Date 7/2/84
1 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
JSec. 3097, Civ. C.).
Lender's Name Far Nest Savings 6 Loan
4001 Mac Arthur Blvd.
Lender's Address Nml+port Boachr 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,
cind hereby authorize representatives of this County to enter
upon the abov toned property for inspection p rposes.
igrwture of Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF,LOS.ANGELES. _. BUILDING AND SAFETY
FOR APPLICANT TO FILL IN - ADDRESS Cl wa.+.741l
BUILDINGADDRESS Garage Cluster for Bldg. #22. LOCALITY b_ Q
NEAREST
CITY Diamond Bar ZIP 91765 CROSS ST.
NO. OF BLDGS. ASSESSOR
SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
TRACT BLOCK LOT NO. USESEGZOONTEL.'
E O Oy^
SPECIAL
OWNER NO. O -N CONDITIONS
ADDRESS 4001 Mac Arthur Blvd.
DISTRICT .GROUP ITYPE,,), FIRE
CONSTZONE
PROCESSED BY
ZIP - CITY Newport Beach CA 92660
ARCHITECT OR TEL.
STATISTICAL
1/yj
CLASSIFICATION APF. CONDO.
ENGINEER `.' NO.- 547-9679 CLASS NO. --v DWELL. UNITS_
ADDRESS 1823 E. 17th - Santa Ana DA SEWER MAP
TEL
CONTRACTOR Koppel Services Inc. NO. 213/595-4871 BK. w, VALIDATION
LIC.
ADDRESS 3703 Long Beach Blvd, NO.-- VALUATION 4623A
CITY L B CA CLASS 0-1
S0. FT. - N0. OF--- NO. OF - CHECK
I N/A 2 1
SIZE 1680 STORIES FAMILIES ONE
S I.y4, 0-?) 1,- -71,40
DESCRIPTION OF WORK NEW 2 /
ADD _. 7 1.4,0Ic
ALTER FINAL I n S 0 7. 19-84
etaehed Cluster -- REPAIR [:]
DATE
USE OFEXISTING BLDG. DEMOI TINA G F 1. E A
APPLICANT .. _ _ - _ TEL. _ - _ . _ _ _ . - - By
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