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HomeMy Public PortalAbout5308 MCCLINTOCK AVE_Building__ ■ - WORKERS' COMPENSATION DECLARATION l I hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERM T insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab: C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Percy No, 1005574 Company Bello Construction LJ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AD�REUG5308 McCulloch Certified copy is filed with the county building inspec- BUILDING 5308 McCulloch tion department. ADDRESS Temple City, CA 91780 Date/ 0/91 Mike Bello CITY Temple City ZIP 91780 LOCALITY Freer & McCulloch Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 37,397 NOW ON LOT —0— NEAREST Freer COMPENSATION INSURANCE CROSS ST. P P 47219 BLOCK LOT NO. MAP BOASSESSOK 1171 PAG67&48 PARCEL (This section need not be completed if the permit is for one TRACT unfired dollars ($100)or less.) OWNER Michael Bello 818 No'.357-4880 USE ZONE NOP 1171 _/`�— Z 7 1 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. CONDITIONS a so as to become subject to the Workers'Compensation Laws. O CITY Arcadia CA zip 91006 Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER Artech 818 NO 445-1882 DISTRICT GROUP TYPE FIRE PROCESSED BY Q Exemption, you should become subjet to the Workers' � O �/, CONST. ZONE V Compensation provisions of the Labor Code, you must forth- ADDRESS 218 Lon don Irwindale �J. 9, V l^j — 3 a with comply with such provisions or this permit shall be Bello Const. 71 599-1245 STATISTICAL CLASSIFICATION APT. CONDO. `n deemed revoked. CONTRACTOR O. Z LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO.�C�DWELL. UNITS % I hereby affirm that I am licensed under provisions of.Chapter ADDREss 2250 Lindsay Way No. 605484 (commencing with Section 7000)of Division 3 of the Business Glendora, C LIC. B SEWER MAP G�� �`` �� and Professions Code,and my license is in full force and effect. CITY CLASS BK PG - VALIDATION SQ. FT. NO. OF NO.OF• CHECK License Number 605484 Lic. Class B SIZE I STORIES FAMILIES ONE 5/10/91 VALUATION Bello Const. Contractor Date DESCRIPTION OF WORK NEW ® $ ❑I am exempt under Sec. construct 7 detached condos ADD El , ALTER ❑ B.&P.C. for this reason REPAIR ❑ I/VV O J USE OF Date: EXISTING BLDG. DEMOL ❑ Sign ure APPLICANT TEL. FINAL OWNER-BUILDE DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License Z Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By - ❑ I, as owner of the ro ert , or m o ees with BUILDING P P Y Y em tP Y ADDRESS wages as their sole compensation,will do the work and , the structure is not intended or offered for sale(Section LOCALITY El�� 7044, Business and Professions Code.) MOVING TEL. El1,as owner of the property,am exclusively contracting Lender's Address CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED YARD Hyyy TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY _SET BACK PROP. LINE WIDTH 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. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name California State BAnk L 3 925 Badillo Covina 91722 P.C. Fee$ Permit Fee . 33J^ LDMA Ref.# ,1 certify that I have read this application and state that the 3 Issuance Fee ' '—� LDMA P/C ti 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. ti r and hereby authorize re�prope tives o this County to enter upon the above-mentioninspection purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE Signa ure of Applicant or Agent Date • WORKERS' COMPENSATION DECLARATIONL o - I 'hereby affirm than I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T insure, or a certificate of Workers' Compensation Insurance, or a certified c th reof(Sec. 3800, Lab C �Y�FbLLS�fG BUILDING AND SAFETY P91icy 14 ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING , � ADDRESS ..ii ❑ Certified copy is filed with the county building inspec- BUILDING �' e ULLIDG �1 tion department. ADDRESS Date Applicant CIN XM rj. ZIP LOCALITY t-� NO. OF BLDGS, NEAREST CERTIFICATE OF EXEMPTION FROM-WORKERS' SIZE'OF LOT [ NOW ON LOT CROSS ST. COMPENSATION INSURANCEASSESSOR (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.) TEL. OWNER NO. d USE ZONE MAP I certify that in the performance of the work for which this NO. 1 Z 7 permit is"issued, I shall not employ any person in any manner ADDRESS SPECIAL :a L�� �r so as to become subject to the Workers'Compensation Laws. CONDITIONS O CITY � � ZIP ` �00(!J` V Date Applicant ARCHITE OR nn TEL. a! NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER 9c _ NO ��� DISTRICT GROUP TYPE r FIRE OCESSED BY. O Exemption, you should become subject to the Workers' 151 �ir,�/ CONST. ZONE lip •0 Compensation provisions of the Labor Code, you must forth- ADDRESS s U(7/( M with comply with such provisions or this permit shall be TEL. p�1_' N - deemed revoked. CONTRACTOR �/�— 0• `f"�� © STATISTICAL CLASSIFICATION APT. CONDO. Z LICENSED CONTRACTORS DECLARATION LIC. � CLASS NO. 42959 DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.U6 (commencing with Section.7000)of Division 3 of the Business LIC. ` SEWERAP .011-0/16 ACC -WI and Professions Code a d y ffhis in full fort d effect. CITY CLASS l BK. PG. -W (DATION SQ.<FFIJ O. OF �1 FA OF CHECK -20/ 385.05 License Num®ber LIC..Cldss SI L- STORIES FAMILIES ONE. /V l /L�j 1 DESCRIPTION OF WORK r' ( NEyy VALUATION TOTAL 1 �� 1��'r a-� Contractor Date 'ADD ❑ j ► 385 ® §. 5 ❑I am exempt under Sec. b l�f,J/� B.BP.C. for this reason ALTER 1-1 $ Date: USE OF , ��7;D� CHECK 385o05 REPAIR 1:1 / OQ0 d CHANGE .e0U EXISTING BLDG. DEMO, F-1 /(�� CHANGE Signature APPLICANT ' l /� EL. IT, OWNER-BUILDER DECLARATION (PRINT) N /'0 NO•q _ DATE FINAL I her affirm that I am exempt from the Contractor's License �f ,r Law for the following reason (Section 7031.5, Business and ADDRESS C/J��L� FINAL E i I AM10:13 Professions Code)- 42E: - PRESENT• BY 6"L"1 3 6 -52 ❑ I, as owner of the property, or my employees with BUILDINGADDRESS a 3 S t`L�i;? wages ct their sole compensation,will f o the work and LOCALITY i the structure is not intended or offered for sale Section j L T�� • j�s.���;� 7044, Business and Professions Code.) MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. cv\. /J - 'C' s"t _1; with Iicensed•contractors to construct the project (Sec- gDDRE55t�ii C tion 7044, Business and Professions Code.) =' REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY. SET BACK YARD HWY PROP. LINE WIDTH hereby rm that there is a sition niiuRON7 ( ;i ` +{the performance.ofhe wok for which thspermtss ed for P .t/0il (Sec. 3097, Civ. C.). SIDE Ll*A 1 " Ar. Cy, P.L. Lender's Name S P.C. Fee$ Permit Fee LDMA Ref. # Lender's Address R C 1 certify that I have read.this application and state that the .7 Issuance Fee /4 LDMA P/C# above information is correct.I agree to comply with all County Investigation lf ordinances and State laws relati g to bbilding construction, Total Fee ! 4 LDMA Perm. # ; = and her by authorizer r sent ives of this County to enter upon t e above-mentio p pro rty for inspection n purpo§es. o '� f � ••SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of A I nt or Agent Date WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to Self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. ZZ `Impony-STFITLI I7U ,,3 A ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the co my bui i g I spec- BUILDING �! II[ .tion department. ADDRESS WIV 1�-1 ,.J V Ct DateL. —Applicant :t� ZIPCITY OF BLDGS. [ t LOCALITY �}— qWv CERTIFICATE OF EXEMPT N F W ER ' SIZE OF LOT NOW ON LOT NEAREST. CROSS ST. V COMPENSATION INSURANCE ., y ASSESSOR (This section need not be completed if the per it is or one TRA (/l BLOCK OT NO. MAP BOOK 11 E PARCEL hundred dollars ($100)or less.) OWNER e n T L�I,L I `( USE ZONE MAP �f I certify that in the performance of the work for which this NO. 1 permit is issued, I shall not employ any person in any manner ADDRESS�- SPECIAL CONDITIONS .so as to become subject to the Workers'Compensation Laws. //''� (�p O CITY C p IP i 7—` V V Date Applicant ARCHITECT OR TEL• DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If; after making this Certificate of ENGINEER NO. CO T. ZO E Exemption, you should -become subject.to the Workers' j�(� d p �� �7 Ix �$ Compensation.provisions of the Labor Code, you must forth- ADDRESS "`��`-^� with comply with such provisions or this permit shall be TEL. ,,// [ STATISTICAL C SIFICATION APT. CONDO. N deemed revoked. CONTRACTOR 11Pe-4J ( 2e-NO. `Y�� Z. LICENSED CONTRACTORS-DECLARATION TE«< • LIC. n CLASS NO. DWELL. UNITS 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �� a �t NO. 2 y b (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP CITY 2C/kms q/rap,6 CLASS `�� and Professions Code,and my license is in full force and effect. BK. PG. VALIDATION 9 y �j �/ SQ. FT. NO.OF NO.OF CHECK License Number o(T��! o • Lic."Class/07—/ SIZE STORIES FAMILIES ONE pp / �± VALUATIONX�0a oO Contractor�-r�_' �Date �n �� T / DESCRIPTION OF WORK NEW ❑ L ADD ❑ ❑I am exempt under Sec. I ar 2 , {"'C"I ' \ ALTER .❑ .SI•: a 4 BAP..C. for this reason AJ J-rA L L A-T / S �' $' USE OF REPAIR ❑ �tj7 rtV a i:� Date: EXISTING BLDG. AO ❑ Z .y T EMS APPLICANT TEL. Signature `��/ s —f c. g OWNER-BUILDER DECLARATION (PRINT) /��P&OA1& NO. L/ T6-1�� FINAL �'OTAI 3- �- t I hereby affirm that I am exempt from the Contractor's License n DATE _ ` _M Law for the following reason (Section 7031.5, Business and ADDRESS I�3 �/}-Y6 R ( � ✓J i FINAL ''HECK i�°.45 Professions Code): PRESENT BY BUILDING 1r.;�1ANGE X00 ElI, as owner.of the property, or my employees with ADDRESS wages as their sole compensation;will do the work and the structure is not intended or-offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. , 13101013-0003 6 18.. r 1 ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. 7iEr ai I+t . with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.)' 'CONSTRUCTION LENDING AGENCY SE?UIRE YARD HWY TOTAL SETBACK FROM WIISTI.1 I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE 3> _ P.L. i i �Ry �: r j C-:. ' Lender's Name r•. C*1 3> r`7 7,• k LDMA Ref. #0_1 i I— 1- a P.C. Fee$ ��J Permit Fee Lender's Address I certify that I have read this application and state that the Issuance Fee LDhAA P/C# above infor ation' orrect. I agree to comply with all County Investigation Fee ordinance and St j relating to building construction, Total Fee $ LDMA Perm. # 1 ( a d h utho isentatives of this County to enter u e abo - eproperty for inspection purposes. =3: �� ri ® r t SEE REVERSE FOR EXPLANATORY LANGUAGE T CO GO Signatu�o PPI nt or Agent Date' -".j ; {tI la� r_`(ri