1260-03 - 436 BUNGALOW DROWNER -BUILDER DECLARATION
I tgrJJy affirm undo/ Penn of Cu,Iun NMI am °secant I.om the Contention. License
Low for the &Athens reason (Sac 7031 E. Butner. aim Pmlessons Otto. Nay thy or
county which mochas a pmmd L, covect Math Improve. demolish, or repair any
.nnxturo. owe to M Hsueae. also teethes the applicant fir such permit to Ire a send
Mammoth that he or the Is thiamin pursuant to the provision CI the Coot/actors L,Mlmn
l.aw ICMolor 9 (avnmarlct•q with Sac. 7000) a Ow 3 or the Business and Fiore, Hes
Coal) at Ma: ha or she Ia exempt Ilnrolronl and the Last for the alleged o[CTµgn. Any
violation of Soc 7031.5 by any nppaulnt for a permit subject to (noon's' to a chid
tenth, of not mare than live nundrod dollars ($00075.
I, CIS uwrot of the property. or my employees "het wages a their the
compmnsatlon, W S do too work, and the at .leturo Is nut intended a offered for that (Soc.
70.14. owner or propers wwoot and oWia+ C. throOodir ws uCnwed. and slWorseow such wodoes rk
nm1lq
heatld or through Na or her ow,. employees, rovidcd MN such Improvement are not
Meade, or Worth for idea it however. the building or improvement Is sold wdhln ado
,ear or ComeithOn. sin wmeNsuMet ions hew rho burden of proving that no or ails did
not wad or improve for The pury0sb of sate.)
:, as owner of the "opfrty. e n ruclusvoly contrasting with ICentad amintlWr to
ruwlruct MuprgM (Sec 7044. BunM'u sty Pm/thanes Coda- The Contractors
Lcense Law doe, not apply to an other of C tony woo builds or improves lhotton, and
who conwas for such month, with a tonbaMi) license pursuant to Inn Contracture
License Law.)
t sin (Comp! under Section _, a B.P.G. for this tension
Dote _,___Sgnetum or Jan ne_, ._-___ _
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY ECONOMIC DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
Elsegundo, CA 00245
24:'R Inspection Request Line: (310) 524. 2379
SITE ADDRESS:
436 BUNGALOW DR
PLAN CHECK/PERMIT NUMBER: 1260.03
DATE: 11 /3/200
NEW
ESIDENTIA
CMP USE:
ADDITION
COMMERCIA
CMP USE:
CMP USE:
E 129 3-(.3
BLDG AREA:
BLDG AREA
BLDG ARE?.:
^6E9CRIsTION OF WORK
RE -ROOF OVER COMP SHINGLES 1 LAYE , NEW COMP
SHINGL ES Ou: of Scope Residential
LICENSED CONTRACTORS DECLRATION
I homey than under penalty of oopury !hall am IKu1LUN Wide' pmwcnns of Chapter 0
;canmonong with Soebon 7000) of Division 3 o! the Buss -trio and Pmtueaions Code.
I. U my Icorife rs in (WI force and efK:
. pass C39. WC LKNember (1432atc Cap Darn ...1.1]0l10M
Ijfare.// 0%41__-tnature of C01,014.1.4c4e.-:E' -•�
WORKERS' COMPENSATION DECLARATION
I Mteb)" aintnundor pantry of punury ow of !no b li:nting otclratroni,
I hays And ale mpnhan a Cetfoato of consent to set -Insure for pnrahNnCJ
camnsatan. as PmvdO ed for by Seve 3700 of (Inctro Labor Code, for the
t the work for warm tfna permit a tanned,
I Nave and'wll maintain workers' co npc,sitan. ac tnquee by Section 3700 T
• 1Code for the ceralwhet of the work for Mach this punt: H Issued. My
waknm' throe +•n:a• nsurnn:e came, and poky number MS
Carrier DALLAS Fi^c___
Policy Number ()WC 02301
Ma b eon rood Ml be sin a1it SwMml aIM Ono Ana d Daum, Math or bet)
w ww o«twmww• w uw w... Air ion rue. wan e/. wow.1 u..,.• amw*IN
w
Rego y manna. Goof plaalwv.Woct b the scars. Wr.auctw kiwi of CM•wMa. ant *Iry
?nil di NnN aMTnvatrt toRenew:Cwnpnma Po.aknaaSC J70001N0kmtCcq,a
.aa,OnMa¢mdjMn nom,nowiee.
dmCA QY - e7 &Walquo n yuili'-
V MNING: FAILURE TO CURE WORKF RS' COt.1PER::AT10N
COVERAGE ISUNLAWFUL. AND SHALL SUDJECT AN EMPLOYER TO
CRIMINAL PENALTIES AND OP/IL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS (1100.000). IN ADDITION TO THE COST OF
COMPENSATION.LLABOR CODE, INTEREST, >Oe OF
AND ATTORNEYS S FEES.
SUITE / IDEN i IFYING NUMBER:
/1rr14-C / ci Mini.:-i d q m' t,.P
ASSESSOR PARCEL NUMBER
Book, 4135 Page: 032 Parcel: 002
REF fI
PRE INSPECTION REO
OCC. CROUP(S) f"E(S) OF CONST
SQUARE FOOTAGE
0
NO. OF STORIES
FIF E SPRINKLERS
YE is NO:
r.
APPLICANT I CONTACT PERSON:
FRANK RICHARDS
ADDRESS:
22029 S. FIGUEROA
CARSON, CA 90745
TEL: (310) 320"0224
STAT CLASS
0/S R
UNIT(S)
$3,400.00
Cc DE IN EFFEC T
r:E C 01
PI AN CHECK FEE 5 _ _ _ O.UC
STORM ':/ATER b 0.0C^
VALUATION ENERGY PLAN CHECI 0.00__
PROPERTY OWNER:
VANPFLT DAVID & TRACEY Y
ADDRESS:
436 BUNGALOW DR
EL SEGUNDO, CA 90245-4043
TEL:
RECEIPT NUMBER
CLERK
EG
0I TE
1113/20(3
ARCHITECT:
ADDRESS:
TEL:
CONSTRUCTIOt1 LENDING AGENCY
I hereby ran ulagpumaty of penury that there w a construction imams agency for the
performance of thesock for which tNs pem!il in .saaM (Sec 3007. Civ. C.1
Lenders Name
Lenders Address
ENGINEER:
ADDRESS:
TEL:
_ _ $C.00 PLAN CHECK FEE C __0.0)
REVISED VALUATION
ENERGY PLAN CHECK $ 0.0)
RECEIPT NUMBER CLERK D \TE
EG
PERMIT FEE
RETENTION FEE
SMIP FEE
ACCELERATED FEE
$ _ 63,G0.___ _.
$ _1,03
$. 050,
$ 0.CD
TOTAL FEES COLLECTED S $4J0-^
CCNI5
term
I have reed 1hth appl Winn and ,late that teo than information S correct. I
. ccmpfywth all city and county ordinances and state Ian rolatt a to building
(ion. and haoby authorize roptesontbves of this city to ea lot upon to, sbovo-
propeM for Inspection purples /7 /y
l/ na i—o $grawm-!asap// �/it 4-`CL—_--
CONTRACTOR:
A-1 ALL AMER ROOFG
ADDRESS:
22029 S FIGUEROA
CARSON, CA 90745-
CITY BUSINESS LICENSE: 13419
CITY COPY
TEL: (310) 320-0224
12/31 /2003
SCHOOL FEES PAID
SANITATION DIST. PAID
PUBLIC WORKS FEES PD.
OSHA PERMIT OBTAINED
HEALTH DEPT, 4PPROV
; FIRE CEPT. APPI?')VAL
SCAOI AD APPROL AL
INDLts "'VIAL WAS FE ARP
RECEIPT NU
s
BEI ISSUED BY
EG
FINALED BY:
(LATE I
DATE 5 ;ac .Boa
•
•