HomeMy Public PortalAbout4500-4502-4504-4506TEMPLE CITY BLVD_Building WORKERS'COMPENSATION DECLARARON ,:; n
1 hereby affirm that I haver certificate of consent race, APPLICATION* FOR 'BUILDING PERMIT DISI
insure, or a certificate of Workers' Compensation Insurance,
or of cvp er f ( 3800 Lab C )
Ohio Casualty Co. l05 ANGELES r BUILDING AND SAFETY
Polity No Company -
Certified c is hereby furnished ADDRESS 4504 T le Cit Blvd.
ILDING
❑ °PY Y FADDREss4504
PPLICANT TO FILL IN
1-1 Certified copy rt filed with the county building inspec-
UU non deportment le Cit Blvd.- - LocaLlTy Temple CityDate 10-4-84 AppjicontLaUghlin Corporation zip 91780 NcOSS ST E. Lower Azusa Rd.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR
COMPENSATION INSURANCENOWONLOT MAP BOOK PAGE PARCR(this section need not be completed if the permit is for one USE ZONEhundred dollars (5100)or less ) BLOCK 4500 Lot 96 NO
TEL - R-4 SPECIAL
_ I certify that in the performance of the work for which this owNERTOwin & Comtry Ind. NO - CONDITIONS IL
permit is issued, I shall not employ any person in any manner - - _ DISTRICT GROUP TYPE FIRE D BV O
so ca to become subject to the Workers Compensation Laws ADDRESS 9608 E. Lower Azusa^Rd. /{� RR CONST ZONE U
me
Date Applicant CTY ARO INFETernple City OR "ZIP 91780 TEL STATISTICAL aASSIFI TION APT CONDO O
NOTICE TO APPLICANT If, after making this Certificate of R DEIDLITION -- NO
Exemption you should become subject to the Workers' NO NO DWELL UNITS
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Compensation provisions of the Labor Code, you must forth- CRESS - _ SEWER,HAP N
with comply with such provisions or this permit shall be -7414 , Z
M
deemed revoked DRACT Tugh In COr�railc% 'BK PG - VALIDATION
LICENSED CONTRACTORS DECLARATION LIC
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Business Center DrZ446338 VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code, and my license is in full farce and effect G CLASS S ►
License Number 446338 Lic ClanB FAZZESQ FT 1200 STOR°5 1 F LIESOF-
Contractor
`o -
ContractorLaughlin Corp. Date 10-4-84 DEscRIPTKTNoFwoRK Demolish existing NEW ❑ s
❑ I am exempt under Sec structures including servicing ADD ❑
ALTER ❑ FINAL ,S A
B 8P C for this reason utilities, vegetation I,conrrptp.REPAIR ❑ DATE G O
Dote USE„TING BLDG R-1 Residence DEMOL ®OF B N
Signature APPLICAM TEL - Y
OWNER-BUILDER DECLARATION PRINT -
I hereby affirm that I am exempt from the Contractor's License 31- ne$$s n er V
Low for the following reason (Section 7031 S Business and ADDRE O C.11 O1730
Professions Code) 2 0 8 3 2 A
❑ y employees BUILDING 4504 Temple Cit Blvd.
I as owner of the _
property, or m em to s with ADDRESS
wages as their sole compensation,will do the work and is e e e e e'J
the structure is not intended or offered for sale(Section LOCALITY Temle C I
7041, Business and Professions Code) MOVING TEL - 1 — 6,1150
Elas owner of the property, am exclusively contracting RACTo�ITOftlas HO NO -
with licensed contractors to construct the project (Sec- ADDjass1448 [`'Lj-Salon Blvd. POfflOna e e * 6(150E'
tion 70.., Business and Professions Code)
CONSTRUCTION LENDING AGENCY �g�p� YARD HWY TOTALP�CK FROM NE tDcoTM It Q05=84
I hereby affirm that there is o construction lending agency for FROM _ polo '
the performance of the work for which this permit is issued p
t5ec 3D97, Civ C ) SIDE
Lenders Name
None PL
8 N/A C F«S F Perms Fee
- Lenders Address
I cemfy that I have read this application and state that the Isuwnce Fee
above information is correct I agree to comply with all County Investigation Fee
ordinances and State jaws relating to building construction, Total Fee
and hereby authorize repress tiv of this County to enter
u no for inspection purposes --
10-4-84 sa IItvEIw FOR FxnANAroar LANGUAGE
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