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HomeMy Public PortalAbout10819 FREER ST_Building__ WORKERS' COMPENSATION DECLARATION J I hereby affirm that I havecertificate of consent to self APPLICATION F.O R BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certi 'e co&tereof (rc. 3800 q . C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N apony BUILDING F ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 1`� 1 ❑ Certified copy is filed with the count building inspec- BUILDING y^p p t' n e artment. ADDRESS l�V a CITY ZIP l' LOCALITY Date Applicant NO. OF BLDGS. CER FICATE OF EXE ION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST CROSS ST. • COMPENSATION INSURANCE I I f I ASSESSOR (This section need not'be completed if the permit is for one TRACTAJ2BLOCK LOT NO. MAP BOOKGE PAR hundred dollars ($100) or less.) OWNER NO / USE ZONE MAP —1 I certify that in'the performance of the work for which this NO. / permit is-issued, I shall not employ any person in any manner ADDRESS' SPECIAL >_CONDITIONS a_ so as to become subject to the Workers' Compensation Laws. 0� O CITY ZIP U Date Applicant ARCHITECT OR c TEL �jf� DISTRICT GROUP TYPE FIRE P OCESSED BY NOTICE TO APPLICANT: If, after.making this Certificate of ENGINEER D N Oa CON E 0 Exemption, you should become subject to the Workers' / * �` U Compensation provisions of the Labor Code, you must forth- ADDRESS C—V CL a with comply with such provisions or this permit shall be CONTRACT TEL STATISTICAL CLASSIFICATI APT. - CO Z deemed revoked. wib _ LICENSED CONTRACTORS DECLARATION / o .11P- NIc O � CLASS NO. �� DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �l Ph (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and li ense is in full force an ffect. CITY CLASS BK PG -.,-VALIDATION ./ SQ. FT. NO. OF NO. OF ECK :•: License Number Lic. Class`'' SIZE I STORIES FAMILIES ONE _ n �{ VALUATION Contractotg r—V'/{!� Date_ `� 5(� .n DESCRIPTION OF WORK NEW ❑ aII-0� ADD ElV O, ❑I am exempt under Sec. Y r 1 ALTER ❑ ► I T t l M BAP.C.,for this reason REPAIR ❑ $ MIA 32, m , Date: USE OF •--� EXISTING BL DEMOL L.L ECK i_, .». -.� Signature APPLICANTEL.qq� FINAL _�_/�� OWNER-BUILDER DECLARATION (PRIM �• NO. 4 1_(-( (i� j 3t DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL, Professions Code): PRESENT Dy t ❑ I, as owner of the property, or m employees with BUILDING '13'1�131T-1I-' '5l.L; P P Y: YADDRESS -i _ wages as their sole compensation;'will do the work and , 756:."i A!i the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- [ADDRESS tion 7044, Business and Professions Code.) CONSTRUCTION LENDING AGENCY ETA.BACEFee TOTAPROP.SETBALINEFROM WIDTH I hereby affirm that there is a construction lending agency for RONT the performance of the work for which this permit is issued .L. (Sec. 3097, Civ. C.). IDE. ^•..1 , = ---1 C-.I t .L. Lender's Name. �•,. �••.t o : Fee A Rdf # Permit FeeLender's Address I certify that I have read this application and state that the Issuance FeeJabove information is correct. I agree to comply with all County estigatI` ( 0 ordinances an State laws relating to building construction, Total Fee �0, LDNsViPerm. # a c ewby horize representatives of this County,to enter upon e b idned property for inspection_ urp ses. t,a is u rt o ��1 . SEE REVERSE FOR EXPLANATORY LANGUAGE...• a d ignat re of Applicant or Agent Date '.",j t',, +M,� -ri I;, a•:= WORKERS' COMPENSATION DECLARATION •L to sf insure bor a certificate of Worke s' Comtpensat on of coent Insuran e, APPLICATION FOR BUILDING PERMIT or a certified copy_thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY .Policy No. 1005574 Company Bello Construction BUILDING © Certified.copy is hereby furnished. FOR APPLICANT TO FILL ADDRESS S-309 He ""u-" _._L iGt�iL/ Certified copy is filed with the county building inspec- -BUILDING _L .. tion department. ADDRESS�r�1�r Temple City, CA 91780 Date 5/10/9plicant Mike Bello cin Temple City ZIP 91780 LOCALITY Freer & Mc Culloch NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 379397 NOW ON LOT -0 NEAREST cRoss ST. Freer COMPENSATION INSURANCEASSESSOR (i NO. 18 (This section need not be completed if the permit is for one TRACT 47219 BLOCK LOT NO. MAP BOOK 1171 PAG647- $ PARCEL hundred dollars ($100) or less.) TEL. Michael Bello 8W357488 USE ZONE MAP �[ OWNER NO. _1 �/- 'L 7 7 I certify that in the performance of the work for which this. permit is issued, I shall not employ any,person in any manner ADDRESS•290 Whispering Pines Dr. .-Z-CONDITIONS 0- so so as to become subject to the Workers' Compensation Laws. OU CITY Arcadia ZIP 91006 Date Applicant ARCHITECT OR TEL. 0 ENGINEER DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of Artech 818 - CONST, ZONE Exemption, you should become subject to the Workers' ADDRESS 218 Longdon Irwindale `/, Ul�. 3 '. a Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. rn deemed revoked. CONTRACTOR Bello Constructiom1o714 599124 X Z 6 U LICENSED CONTRACTORS DECLARATION 2250 Lindsay Way NO LIC. 605484 CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS SEWER MAP (commencing with Section 7000)of Division 3 of the BusinessCIS Glendora CLASS B and Professions Code,and my license is in full force and effect. BK, PG. Cr-1:�- VALIDATION SO. FT. NO. OF NO. OF CHECK License Number 605484 Lic. Class R SIZE I STORIES FAMILIES ONE VALUATION ContractorBe110 COnBt. Date 5/10/91 DESCRIPTION OF WORK NEW $ construct 7 detached condos ADD ❑ ► ❑I am exempt under Sec. ALTER ❑ p B.&P.C. for this reason REPAIR ElS/6k USE OF 00.0 1&0 Date: EXISTING BLDG. DEMO/ [E]'�..- APPLICANT TEL. Signaf6re �) Dat AA _ FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT BY BUILDINGEl I, as owner of the property, or my'employees with ADDRESS wages as their sole compensation,will do the work and , the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. © I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.). REQUIRED TOTAL SETBACK FROM EXIST. •- � ' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT ","S i the performance of the work for which this permit is issued P.L 'l (Sec. 3097, Civ. C.). SIDE California State Bank P.L. Lender's Name , LDMA Ref. # ' 925 Badillo Covina 91722 P.C. Fee$ Permit Fee S Lender's Address , 1 certify that I have read this application and state that the ~� 3 ' Issuance Fee 3' CO LDMA P/C# o _ 8 above information is correct. I agree to comply with all County Investigation Fee / - ordinances and State laws relating to building construction, Total Fee ` _ LDMA Perm. # a and hereby authorize representatives of this County to enter upon 4he above-mentioned pro rty i ection purposes. SEE REVERSE FOR-EXPLANATORY LANGUAGE Signature of Applicant or Agent Date LA_ 3- WORKERS' COMPENSATION DECLARATION • •I hereby affirm that I have a certificate of consent to self ir&ure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certifie ppye�eof (Sec. 3800, La . COUNTY OF LOS ANGELES BUILDING AND"SAFETY Policy No. G� ( Company' ❑ Certified co is hereb furnished.. FOR APPLICANT TO FILL IN BUILDING py y ADDRESSin ❑ Certified copy is filed with the county building inspec- BUILDING D Fe EER tion department. ADDRESS Ap /� CITY: /viYl�� ZIP LOCALITY Date Applicant P� NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 3 t NOW ON LOT NEAREST COMPENSATION INSURANCE CROSS ST. `7 ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. / MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) r 1n j NO nom USE ZONE OP o2 77 OWNER V / I certify that in the performance a the work for which this A �J S �� SPECIAL r permit is issued, I shall not employ any person in any manner ADDRESS I L /C_v` CONDITIONS so as to become subject to the Workers' Compensation Laws. �^ 0 CITY R'C ZIP Q0 V Date Applicant ARCHITECTOR TEL, 1 7, e 2 DISTRICT GROUP TYPE ,.+� FIRE P CESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER 2 e C - NO.` y� v CONST. , / ZONE U Exemption, you should become subject.to the Workers' 2� ��� �D �, _ I/ � Compensation provisions of the Labor Code, you must forth- ADDRESS t h .........ILII --- with comply with such provisions or this permit shall be / NO STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR �L Z LICENSED CONTRACTORS DECLARATION LIC. n(� CLASS NO. �0 DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. G 1 LIC. SEWER P (commencing with Section 7000)of Division 3 of'the Business � /fJ� CITY CLASS and Professions C d an my license is in full force d effect. BK.&" PG�- !�NT (DATION Qy' U SQ., NO. OF NO. OF CHECK License Number 1 ` Lic. Cldss� SIZED STORIES IFAMILIES ONE 3307 385.05 `�J �/y �' �^ q-^ VALUATION 1 ITEMS Contractor_AA I g—50/ Date ` DESCRIPTION OF WORK &t)�J NEW EI I am exempt under Sec. 0 � ADD ❑ � POP- TOTAL 31.35-05 9 ALTER E] B.&P.C. for this reason REPAIR ElS n CHECK 385.05 USE OF Date: EXISTING BLDG. DEMOL ❑ Qw� CHANGE .til] Signature APPLICANT TEL• _���� FINAL OWNER-BUILDER DECLARATION (PRINT) // D NO. /J l/ oP J DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL t�1i Professions Code): PRESENT By o� tit; _•I `; A I10'-13 BUILDING I Gt 1 ❑ I, as owner of the property, or my employees with ADDRESS '- wages as their sole compensation,will do the work and �/ i L(HL the structure is not intended or offered for sale(Section LOCALITY E;.' s•.1+ani, 7044, Business and Professions Code.) MOVING - � TEL. (:)"�-�•�'••� ❑ a1=I, as owner of the property, am exclusively contracting CONTRACTOR NO. >: lt�tif3� , with licensed contractors to construct.the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 010111D-C1C01 _/ZU" I hereby affirm thatthere is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. :4!t� ,fir? (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name. P.C. Fee$ 5, Permit Fee ' LDMA Ref. # Lender's Address ZLd Poll. o I certify that I have read this application and state that the ` Issuance Fee LDMA P/C# o above information is correct. I agree to comply with all County Investigation Fee � 0 ordinances and State laws reI tin to building construction, Total Fee T" LDMA Perm. # a and hereby authorize re re entati es of this County to enter upo the above-mentio grope for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE. Signature of Appli a t or Agent Date