HomeMy WebLinkAbout4625A 0807A 0808AWORKERS' 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.WP80033111 Company . Assor. Indemnity
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date 4/84 Applicant Koppel Services Tne-
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
Professions Code, and my license is in full force and effect.
License Number 287828 Lic. Class B1
Contractor Koppel Services Inc. Dote 7/2/84
I am exempt under Sec.
B.&P.C. for this reason
Signature i
OWNER -BUILDER DECLARATION '
I hereby affirm that 1 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 sale compensation, will do the work and
the structure is not intended or offered for sole (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 West Savings E Loan
4001 Mac Arthur Blvd.
tender's Address Newport Beaeh, CA
I certify that I have read this application and state that the
above information Is correct. 1 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 abov me tinned property for inspection urposes.
Signmure of Applicant or Agent
7
D.X.
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES- _ BUILDING AND SAFETY
FOR APPLICANT TO FILL IN -
BUIL
nooaess l Gwo ter+ fig
ADDRESS Gara a Cluster Far Bldg. f{18 LOCALITY ' '
NEAREST
CITY Oiatinrid Bar ZIP 91765 CROSS ST.
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT None
ASSESSOR
MAP BOOK PAGE PARCEL
TRACT 34831 BLOCK I LOT NO,
USE ZONE MAPNO. Q
SPECIALTEL. - 3
OWNER W NO. CONDITIONS
ADDRESS 4001 Mac Arthur Blvd.
DISTRICT GROUP TYPE
NSTCOtJ
FIRE PROCESSED BY
ZO
1IYY//. Iv MCITYNewportBeach, CA ZIP 92660
ARCHITECTOR TEL.
ENGINEER ked Noltz E Assoc. NO.547-5679
STATISTICAL CLASSIFICATION
CLASS NO. '2_0 DWELL. UNITS_
APT, CONDO.
ADDRESS 1823 E. 17th _ SEWER MAP
TEL 213CONTRACTORKoppelServicesInc. No. /595-4871 8K. PG, VALIDATION
ADDRESS 3703 Long Beach Blvd. NO.287828 VALUATl
2
5462.,A
CITY Lon Beach CA CLASS B-1
CHECK
S. r lop.9 23SO. FT. NO. OFNO. OF
SIZE 840 STORIES 1 FAMILIES N/A ONE
13, u7d I • •59,50
DESCRIPTION OF WORK NEW ®
ADD . El• 5 9.5 0 Z
4) Car Garage
DATEL
9 0719-84
REPAIR
USE OF DEMOL FINAL{, 8 {) % Fi
EXISTING BLDG. BY
SEE REVERSE FOR EXPLANATORY LANGUAGE
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