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Home My Public Portal About5313 MCCULLOCH AVE_Building__ '.WORKERS' COMPENSATION DECLARATION Co I '.I hereby affirm that I have certificate of consent to self P P L I CAT I® FOR P�I L D I PERMIT insure, or'a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES UILD G AND SAFETY "Policy No. 104 Company ell o Construction BUILDING n& -549& McCulloch n Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ly1 Certified copy is filed with the county building inspec- BUILDING CCu OC tion department. ADDRESS 60Temple City, CA 91780 Tem a City 91780 Date 5/110_ /91 Applicant Mike Bello ,CITY ZIP LOCALITY Freer & McCulloch NO.OF BLDGS.CERTIFICATE OF EXEMPTION FROM WORKERS' J�EENGINEER IZE OF LOT 37,397 NOW ON LOT —Q— NEAREST CROSS ST. � COMPENSATION INSURANCE (This section need not be completed if the permit is for one RACT 47219 BLOCK LOT NO. 1 ASSESSOR MAP BOOK 1171 PAGE 47& 8 PARCEL ` hundred dollars ($100)or less.) NO I certify that in the performance of the work for which this 290 Whispering Pines Dr. SPECIAL } permit is issued, I shall not employ any person in any manner DDRESS p g �^ CONDITIONS / a0 so as to become subject to the Workers'Compensation Laws. ITY Arcadia CA ZIP 91006 U Date Applicant RCHITECT OR EL W NOTICE TO APPLICANT: If, after makingthis Certificate of Artech 81$vo,445-1882 DISTRICT GROUP TYPE IRE PROCESSED BY O /1CONST. ONEExemption, you should become subject to the Workers' 218 Longdon Irwindale ;: 'O0 ^3Compensation provisions of the Labor Code, you must forth- DDRESS with comply with such provisions or this permit shall be TEL �: STATISTICAL CLASSIFICATION APT. deemed revoked. CONTRACTOR Bello Const. 714 NO,599-1245 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 (commencing with Section 7000)of Division 3 of the Business Glendora, CA 91740 LIC• B SEWER MAP -yO�G and Professions Code,and my license is in full force and effect. CITY CLASS BK PG a--C a— VALIDATION SQ. FT. NO.OF NO. OF CHECK License Number 605484 Lic. Class B SIZE I STORIES FAMILIES ONE VALUATION Contractor Bello Const. Date 5/10/91 DESCRIPTION OF WORK NEW ❑1 am exempt under Sec. construct 7 detached condos ADD ALTER ❑ p-ti BAP.C. for this reason IREPAIR ❑ $43q Uad Date: ;USE OF � EXISTING BLDG. DEMOL ❑ SigriQture APPLICANT TEL. FINAL OWNE -BUILD DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License DATE Law for the following reason (Section 7031.5, Business and °y ADDRESS FINAL e �A_# Professions Code): PRESENT By BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY 77 the structure is not intended or offered for sale(Section 7044, Business and Professions Code.) MOVING TEL. I, as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. ' Lender's Name ('al i forni a State Bank 8 925 Badillo Covina, 91722 P.C. Fee$ Permit Fee 1 LDMA Ref. # Lender's Address 1 certify that I have read this application and state that the " 5'?., 13 Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee �r ordinances and State laws relating to building construction, Total Fee / LDMA Perm. # and hereby authorize representatives of this County to enter u on the above-mentioned ope rt spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or gent �Dote ' ,WORKERS' COMPENSATION DECLARATION J hereby•affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or'a certificate of Workers' Compensation Insurance, ora certified cop thereof(Sec. 3800, La . C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NO.�y m Company FJ� ElBUILDING Certified copy is hereby furnished. 4-1 y/ FOR APPLICANT TO FILL IN ADDRESS '- ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 33 l )^ CITY IMP L.' ZIP e C L, Ar/ LOCALITY �C; Date Applicant NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LO NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. I'77 /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 !� SPECIAL p / CONDITIONS so as to become subject to the Workers'Compensation Laws. AP e,4 A ZIP l !VO� U CITY Date Applicant ARCHITECT OR /j n� C� TEL.NO 2 DISTRICT GROUP TYPE FIRE ROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER (jy[ Exemption, you should become subject t the Workers' �� ' J�(/ �`� CONST JE aCom ensatijon rovisions of the Labor Code, ou must forth- ADDRESS va N with comply with such provisions or this permit shall be STATISTICAL CLASSIFICATION APT.IF CONDO. Z deemed revoked. CONTRACTOR LICENSED CONTRACTORS DECLARATION LIC. r'I�T7h CLASS NO. 470 DWELL. UNITS _ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.'"L, L•1�L!C (commencing with Section 7000)of Division 3 of the Business LICSEWERAP • A / A4i• y and Professions Code,and hmy license is in full force d effect. CITY CLASS BK �� Mj&IDATION _ �`L� SQ. FT. ¢ NO.OF NO.OF y CHECK n t License Number F L I ic. Class SIZE f STORIES FAMILIES l ONE 3307 604.3'5 N1 U�-�L- 1 a'1!-'� (� vALs �� 1 ITEMS Contractor Date DESCRIPTION OF WORK NEW r ❑1 am exempt under Sec. 0 P V ADD ❑ TOTAL 604.35 ALTER 1:1moo+ eo .HECK X504=335 REPAIR B.&P.C. for this reason Date: CHANGE =1111 USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANTA TEL• FINAL OWNER-BUILDER DECLARATION (PRINT) Q NO.`[ t7 I hereby affirm that I am exempt from the Contractor's License r7 L /�/1T DATE I]I1��_�yQf}1 1�111� Law for the following reason (Section 7031.5, Business and ADDRESS F FINAL Professions Code PRESENT By ❑ I, as owner of the property, or my employees with BUILDING ADDRESS 3 117 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. y9C�� j_f j}1L with licensed contractors to construct the project (Sec- l /�J'G• q CHECK tion 7044, Business and Professions Code.) ADDRESS / ,{�Q'// :.Fj �.lti i1T 7,3� REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. ►N/� ::��flfr]t =1 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 �(�{I'r —>"{If'li M;,f, ':fr=_ P.L. t •J is ai Lender's Name r==�I�` y�- 8 D 1:1- 5 Q/� ��. LDMA Ref.N P.C. Fee$ ePermit Fee !J u Lender's Address •� )�/ I certify that I have read this application and state that the C+� Issuance Fee /✓ �— LDMA P/C N 3 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws elatin to building construction, Total Fee • LDMA Perm. N and hereby authorizer r sentat es of this County to enter upon the above-mentio prop. for inspectiiown pur oses. .V�L �� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applic t or Agent Date