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Home My Public Portal About5312 MCCULLOCH AVE_Building__ . ' . WORKERS' COMPENSATION DECLARATION Cc ti I hereby affirm that I have a certificate of consent to self ®`� ®R "WILDING PERMIT insure, ora certificate of Workers' Compensation Insurance, ®"'fa ora certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY - Policy No. 1005574 Company Bel J D construction BUILDING ® Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS .5409-McCulloch ® Certified copy is filed with the county building inspec- BUILDING X5308. McCulloch Temple City, CA 91780 tion department. ADDRESS Date 5/10/91Applicant Mike Bello CITY Temple City zip 91780 LOCALITY Freer & McCulloch 37,397 NO.OF BLDGS. —0— NEAREST Freer CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE 47219, ASSESSOR 1171 47&48 (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.) OwNERMlchael Bello SIS Tj,� USE ZONE MAP 4/ - - -77 I certify that in the performance of the work for which this NO. SPECIAL 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 v Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Artech 818 N .445-1882 CONST. ZONE w a t— Exemption, you should become subject to the Workers' 218 Longdon Irwindale Js�'"p� 3 Compensation provisions of the Labor Code, you must forth- ADDRESS 1 .3 with comply with such provisions or this permit shall be TELNDO. deemed revoked. CONTRACTOR Bello Const. 7142.599-1245 STATISTICAL CLASSIFICATION APT. CONDO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 2250 Lindsay Way NO.605484 �p (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY Glendora 9CA 91740 CLASS B BK PG D + � VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number 6054194 Lic. Class R SIZE I STORIES FAMILIES ONE VALUATION Contractor BP11 n rnnet- Date 5/1 n/91 DESCRIPTION OF WORK NEW $ ADD El ❑1 am exempt under Sec. construct 7 detached condos ALTER ❑ ' b _ B.BP.C. for this reason REPAIR ❑ $Aa/O Oo USE OF 0 Date: A :'. EXISTING BLDG. DEMOL ❑ �' oD Si n�rura r APPLICANT TEL. i g OWNER-BUILDER DECLARATION (PRINT) NO. FINA a DAT = [ Z•f I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL v Professions Code): 'PRESENT By ❑ I, as owner of the property, or m employees with BUILDING P P Y� YADDRESS wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code.) MOVING TEL. ® I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIREDTOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE Lender's Name California State Bank ' P.L. Lender's Address 925 Badillo Covina 91722 P.C. Fee$ Permit Fee LDML# ] 1 certify that I have read this application and state that the / Issuance Fee LDMPooabove information is correct. I agree to comply with all County Investigation Fee 3 ��ordinances and State laws relating to building construction, - Total Fee /r1 ry LDM and hereby authorize representatives of this County to enter u on the above-mentionedRroperty for i ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or gent Date '' • " WORKERS'COMPENSATION DECLARATION �^ I hereby affirm that I have certificate of consent self ®PLIC® ® I® F®R R M I L®I N G PERMIT insure, or'a certificate.of Workers' Compensation Insurance, ® !>�v ora certified op �tereof(Sec. 3800, .C. COUNTY OF LOS ANGELES BUILDING AND SAFETY • Policy No Company BUILDING ❑ Certified copy is hereby furnished. �f/ FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING C o� tion department. ADDRESS wy c C Q4i LOCALITYDate Applicant NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE 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.) q EL' � MA .12'� V G NO. USE ZONE NO. P �,� /-/.1-17 I certify that in the performance of the work for which this OWNER J permit is issued, I shall not employ any person in any mannerADDRESS19 -2 r� 2 , SPECIAL a so as to become subject to the Workers'Compensation Laws. o f Vp� CONDITIONS Q (l` 0 V CITY ZIP Date Applicant ARCHITECT OR TEL. {- f, P Y I n 2��'� 7 J J DISTRICT , ROUP TYPE FIRE PROCESSED BY Q Exemption, NOTICE TO APLICANT: If, after making this Certificate of ENGINEER ppTT��// ��NO `L//J17/6/ 3 CONST ZONE q/^ Exem tion, ou should become subject to the Workers' � Compensation provisions of the Labor Code, ou must forth- ADDRESS with comply with such provisions or this permit shall be STATISTICAL CLASSIFICATION A CONDO.revoked. CONTRACTOR L NZ — LICENSED CONTRACTORS DECLARATION LIC. )fL117/�� F CLASS NO. ®Q DWELL. UNITS — ADDRESS hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWE P (commencing with Section.7000)of Division 3 of the Business LIC. /® and Professions Code my lice a is in full foPeffect. CITY CLASS BK�' 7 j VALIDATION n SC�r�f) NO.OF NO.OF CHECK ACCTA License Number-01 l Lic. Class SI7g� STORIES l�/�F,A�MILIES ONE ACC A Contractor /VI1_19 p Date � (� 'DESCRIPTION OF WORK �t9t :� s(� NEW VALUAT ON O 3307 385.05 wA 7q ADD ❑ s...n ,:.iJ t T ❑I am exempt under Sec. ®� V ALTER ❑ ,` ,�'1 y�MS B.&P.C. for this reason REPAIR ❑ z $ TOTAL �`� Dote: USE OF BDD yh r.�F 3$r?oLI.{ EXISTING BLDG. J DEMOL ❑ MCK Signature APPLICANT(PRINT) —_:A L FINAL {-) t� I C oQQ OWNER-BUILDER DECLARATION O' GJL �7 '' I hereby affirm that I am exempt from the Contractor's License s. DATE 36U Law for the following reason (Section 7031.5, Business and ADDRESS FINAL {-�I•y��r�' -y_. Professions Code): PRESENT By 0,1 t94ii- � 10/11/89 BUILDING 4 ❑ I, as owner of the property, or my employees with ADDRESS 1n 1� wages as their sole compensation,will do the work and ¢ the structure is not intended or offered for sale(Section LOCALITY VING TEL. :E•.» �y,�g� ':HECK tsi`rir o^ 7044, Business and Professions Code.) CONTRACTOR NO. C *-f / 1-jq ;j� otlt ❑ I,as owner of the property,am exclusively contracting q with licensed contractors to construct the project (Sec- ADDRESS te""-471 tion 7044, Business and Professions Code.) J�' ' REQUIRED AllYARD HWY TOTALSETBACKFROM EXIST. 1,3q(e OQGO-130;31 5/210/91. 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. �Li�4 °i- (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name Jr�� LDMA Ref. # / Permit Fee o/ Lender's Address l I certify that I have read this applicati nand state that the Issuance Fee /3 LDMA P/C# above information is correct. I a ree to mply with all County Investigation Fee �� ordinances nd State laws rel ting t building construction, Tatal Fee LDMA Perm. # and herebi authorize repres tative of this County to enter 2� upon the ove- entione oper o inspectio purpos o n? SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Applican r Agent Date WORKERS' COMPENSATION DECLARATION hereby'affirm that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T insure, or a certificate of Wor ers' Compensation Insuranc or a certi e t r -ac.c. 38 ab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. C �blp� 4BUILDING ❑ Certified copy is hereby furnished. nished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the coup uilding inspec- BUILDING ti n tyd� p r ment. ADDRESS Date a ApplicantZCITY ZIPTJ B LOCALITY N OF DGS. NEAREST ERT ICATE OF E=PINN FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAG P L hundred dollars ($100)or less.) T s n /� SPECIAL } permit is is ued, I shall not employ any pers i any manner ADDRE U eYJ nh CONDITIONS a- so as to b o subject to the er C p nsat' L ws. CITYAfCA ZIP O Date G ' Applicant ' ARCHITEtTO TTL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, afte rma ting`this Certificate of ENGINEER NO. CONcz�' O Exemption, you should become subject to the Workers' � 13 Compensation provisions of the Labor Code, you must forth- ADDRESS2jV 11 a- with comply with such provisions or this permit shall be p &L&I STATISTICAL CLAS ICATION APT. CON N deemed revoked. CONTRACTqze5 i"J ..V Z LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES O V NO SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code, nd m lire is in full force and effect. CITY C beBK PG VALIDATION SQ. FT. NO. OF NO.OF CHECK License Number Lic. Class SIZE STORIES FAMILIES ONE ��.ii VALUATION Contractor s Date DE PiION OF WO NEW ❑ � 14� s DD PIU,1 ❑I am exempt under Sec. ADD El =�;o ALTER ❑ BAP.C. for this reason REPAIR ❑ $ Iti j` Date: USE OF EXISTING BL DEMOL 0 TOTAL • 3 _25 Signature APPLICANTr• ''x` OWNER-BUILDER DECLARATION J FINAL (PRINT) NO, CHECK _ .:• I herebyaffirm that I am exempt from the Contractor's License ,f DATE "g—�7i �� I�l P ADDRESS tI t' �'�E ' Law for the following reason (Section 7031.5, Business and FINAL Professions Code): PRESENT By El BUILDING I, as owner of the property, or my employees with ADDRESS [ILf00—t_011 6/1S%?1 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ® �� ii e)_T 7044, Business and Professions Code.)' MOVING TEL. r` 3 1 AM❑ 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 SETT BACK YARD HWY TOTAL SETBACK LINEFROM 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. "a a at Lender's Name Iv P.C. Fee$ Permit FeeCi v Lender's Address I certify that I have read this application and state that the Issuance FAe' / �� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee + I ordinances an Tate las relating to building construction, Total Fee ' d+ LDMA Perm. # ( and by ut orize rwepresentatives of this Count to enter t n e o - d property for inspectioryFpurp9g.s.74 Z6/ SEE REVERSE FOR EXPLANAf6*Y.k4NGUAGE , n Sig ature of Applican r Agent Date ;? '" r': '+