HomeMy WebLinkAbout4624A 0823A 0824AWORKERS' COMPENSATION DECLARATION
I 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.)
PolicyNo Company
Cern ie cop{enni LTCeyisherebyfurnishei(: ---- --
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.)
1 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, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Lobor.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 7ODD) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 2137828 . Lic. Class BI
Contractor Koppel Services Inc. Date 7/2/84
F1I 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 sole (Section
7044, Business and Professions Code).
0 I, as owner of the property, am exclusively contractingwithlicensedcontroclorstoconstructtheproject (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.).
Lenders Name Far West Savings C Loan
4001 Mac Arthur Blvd.
Lender's Address Newpopt Reach, CA
I 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
upon the ab -m ntt ned property for Inspection purposes.
d f
S afore of Applicant or Agent to
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES -.. BUILDING AND SAFETY
FOR APPLICANT TO FILL IN A oWING C
BUILDING
ADDRESSGara a Cluster For Bldg. //24 LOCALITY. s
Diamond Bar 91765CittZIP NEARESTCROSSST.
NO. OF BLDGS. ASSESSOR
SIZE OF LOT NOW ON LOT None MAPBOOK PAGE PARCEL
USQEzONE MAP
TRACT 34831 BLOCK LOT NO. 3.' N0.
IAILOWNERFarWestSavingsELoanNo833-8383
s
CONDITIONS
DISTRICT GROUP TYPE FIRE PROCESSED BY
ADDRESS 4001 Mac Arthur Blvd. CONST. ,
r
ZONE
l
C -
AJ // r
CITY N ZIP-. CA 6 STATISTICAL CLASSIFICATION APi. ONDO.
ARCHITECT OR TEL.
ENGINEER lied Maltz E Assoc. No.547-5679 rTAss No. DWELL UNITS
ADDRESS _ SEWER MAP
TEL
CONTRACTOR Koppel Services Inc. NO'.213/595-4871 BK. - PG, VALIDATION
3703 Lon Beach CA LIC- 287828ADDRESS9rNO.
CITY Long Beach, CA UC. CLASS B-1
VALUATION
a
04624A
1 NO. OFS°'E"' 1680 N/A CO Z 1
EKSTORI0
S i" 7 4
DESCRIPTION OF WORK NEW ® I , • • 1. 0
ADD 7.1.4 0 EeCarGaraa
ALTER FINA-
DATE 13 3 o719-84
REPAIR
SOFUSEOF
DEMOL. FINAL - - FI
EXISTING BLDG. - --
APPA Ir ANT TFI
BY
SEE REVERSE FOR EXPLANATORY LANGUAGE
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