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HomeMy Public PortalAbout4509TEMPLE CITY BLVD_Building (2) WORKERS COMPENSATION DECLARATIOpJ r �J hereby affirm that I have t certificate of consent to self insure FOR BUILDING PERMIT re or acertifcertificateC certificate of Workers' ompensbon Insurance or p_ elh}I�d Eopy thereof (Sec 3800 Lab C ) + ICOUNTY OF LOS ANGELES BUILDING AND SAFETY �!o IcUyf0221j 3050526 Company Ohio Casualty Certified copy is hereby furnished FOR APPLICANT TO FILL IN ' AD REISSSS Q . PiI7u ® Certified copy Is filed with the county budding mspec BUILDING tion departmentDonald F. Laughlin AooREss 4509 Temple City Blvd, LOCALITY i Dote Applicant Construct3.on Company aTVT le Ci - ZIP 91780 CRROSSST Ier CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT 77 'X150' irre NO OF ON LOTS NONE MAP BOOK PAGE ASSESSOR PARCEL COMPENSATION INSURANCE (Thu section need not be completed if the permit a for one USE ZONE MAP TRACT 12998 eloac 37 Lor nto 23 No hundred dollars (5100)or less ) Y I certify that in the performance of the work for which this OWNER Ja co Acceptance Corp or TEL CONDITIONS 0 ; permit is Issued I shall not employ any person In any manner DISTRICT GROUP TYPE FIRE PROCESSED BV U "so as to become subject to the Workers Com ensahon Laws ADDRESS 9604 Lower Azusa Road f D„f CONS ZONE pc Donald pF„LaughlinTemple CITY Ci zip 91780 0 Date Appl,co nt STATISTICAL CLASSIFICATION APT CONDO V NOTICE TO APPLICANT If after ma ung t Is .,P icote of ARCHITECT OR Van Dam TE d Exemption you should become subject to the Workers ENGINEER C• 14-621-6 CLASS NO 1-6 DWELL UNITS_ Compensation provisions of the Labor Code N p p you must forth 1420 N. Claremont B1. Claremont2. 2 . SEWER MAP ? with comply with such provisions or this permit shall be �,p deemed revoked c�WL F. Laughlin ConstrA�14-982-608 BK L PG 10 VALIDATION LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 314 Euclid Pl. NCO 326065 VALUATION (commencing with Section 700))of Dlvlsron 3 of the Business and LIC Professions Code and my license is in full force and effect CITY Upland, CA 91786 CLASS f 200 000.00 326065 SO FT NO OF NO OF CHECK _ License Number L4 Class B SIZE 4752 STORIES 2 FAMILIES N/A ONE % Donald F. Laughlin ® f Contractor eanstraction Dote Sept, 1976 - DESCRIPTIONOF WORK: Two story wood gNEEW 19 I am exempt from the licensing requirements as I am a frame/stucco financial lnstltU loll ❑ licensed architect or a registered professional engineer ALTER [] FINAL acting In my professional capacity (Section 7051 office H .Bld . w/ ark2-n Boland ${. ❑ DATE Business and Professions Code) _ USE OF EXISTING BLDG N/A DEMOL ❑ FINAL LK or Reg Na Date APPLICANT 9T — OWNER BUILDER DECLARATION PRINT Donald F. Lau hhn NTE`d 14-982-60 I hereby therm that I exempt from the Contractors ADDRESS 314 Euclid Pl.. Upland. CA 91786 53 f Law for the followingg r reason (Section 7031 5 Businessss and d Professions Code) _ N/A �3 4 BUILDING as owner of the property or my employees with ADDRESS t N A wages as their sole compensation will do the work and N/A 1 ;S'6 2 4,6 A the structure Is not Intended or offered for sale(Section LOCALITY , , 7044 Business and Professions Code) MOVING TEL I $&743 I os owner of the properly am exclusively contracting CONTRACTOR N/A NO N/A t . PO �! • • • • • 1 A wit44 h licensed contractors to construct the project (Sac N/A - hon 70Business and Professions Code) ADDRESS N/ R '7 2 1 1 8 7 5 0 REOUIREDTOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD Hwv PROP LINE WIDTH • 1 1 8 7 5 0 csi I hereby affirm that there Is a construction lending agency for FRONT the performance of the work for which this permit is Issued P L '0 9 1 5-8 2 (sec 3097 Civ first City SIDE - PL Lenders Nome.Qp l- c.:p /f , lenders Address 9000 E. Valley, Rosemead CA PC F..$ Permit Fee / > I certify that I have read this application and state th t 0 Issuance Fee above information is correct I a ree to coin with all Count r 9 comply Y Invesngonon Fee ordinances and State laws relating to building construction and hereby outhonze re resentahves of this County to enter /�� L Total Fee {� upon th above men ed properly for mspechopn' urposes IJP S 7 1 — 97 31:s / Y D, r E - SE REVERSE FOR EXPLANATORY LANGUAGE I ^ Igrwty o App icon,a gent