118-03 - 2000 IMPERIAL HWY E (3)VERSION 13-3000
OWNER$UILDER DECLARATION
I hereby affirm under penally of penury that I am - , Imo the Contractors 1
License Lew for the tall0waq reason (Sec 1031 : and Protessins t.ode
My ay or county Mach requires a pant to••• - trud-ate snprove demolish or
repair enY structure pep Was issuance else .., .:: the spplCint to such perms
W TM a signed statement Mat he or she Is - sal pursuant to the prVneIXls of the
Contacicee Lknse Lim (Chapter 9(-• - • with Sec 7000) of Div 3 of the
Bann,, and Pmtessions Lode} or :- • Or We b exempt therefrom and me bass
for the aleged exemption Any .... of Sec. 1031 5 by any appllc+ll for a pemd
the e applicant toun a d• .:1 of not more than five hundred dollars (S500))
LJ 1 as rimer of the ..... or my empioyees won *ages as mew site com-
pensation wd8 do the wok :, . the sbuctue is not Wended or offered for sale (Sec.
7044 Business and lid..... Code The Contract*, Lambe Law dos not
apply W an owner of • • • *lio builds or mammas thereon and who does such
wo t Mmser or horsed - through Ns a her awn employees pounded that such
Improvements are • tended or offered for sale If however the bulldog or Im-
provement is sad one year a sandmen the owner -budder wet nave the
Baden d promo :I he or she did not bold or improve ice the purpose a sere l
I a5 . of the property an exclusively Uad g with licensed c n-
tradors W •. . Me dyed (Sec 7044 Busness and Professions Code The
Contractors •:. se Law does not apply W an owner d properly who bake a 1m-
pave! • and vao contracts for such protects Mt a cis tada(s) hce1se
pursuant the Contradoa License Law )
1 exempt under Becton B &P C for ftvs reason
Date Signature of Owner
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of penury that I am Licensed under pmnsea of
Chapter 9 (commencing with Sedan 7000) of Division 3 of the Business and
Pmpsicos LODE and my WCenne is in Mn terse and enact ''')-/-°J
t
/ /1 2- /
License lass I. Expiration Date
Date Ignal Contractor
WORKERSCOMP RATION DECLARATION
I hereby affirm under penalty of ry one of the following declaration
I♦ I have and wet maintain a Platte d consent W self -Insure for workers
compensation as provided for by Seaman 3700 of the Labor Cote for the per
formance of the wok for wick tits permit is Issued
I here and will maintain workers compensation Insurance as required by
/W of tre Labor Code for the petamance d to work tor which Ws permit
Is Issued My workers compensation nce camel and pact number are
Coder S y' 4 L, /
Poky No WVKG/o OGy(
IhM MST need rcI be rmpwtl Ma I1emi s le w *rLLse Ken I51 W I o mint
Inf t comfy that In the performance of the work for which this permit is issued
1 gall nit employ any person in any manner So as 10 become dyed W Om makers
laws Califaaa
oalgmsalon of and agree tat d I shoed become svt e.1 W the
workers comports/nal provsicns at Se TW of Labor Code shaft fathw,th
WTpr, won moss prWlSCns
y7-07
Date Signature of Apprpanl
WARNING FAILURE SECURE WORKERS-CtaatwaA HON
COVERAGE IS UNLA AND SHALL SUAIECIAN EMPLOYER TO
MYNA! S AND MIL FRIES UP TOONE HUMORED
n.OIl3AND DOLLARS 0100,,0004 IN AMNION TO THE COST OF
coupons nom,M WOES AS PRO1SED FOR N SEC HON 370e OF
THE L*8OR CODE. INTEREST, AND ATTORNEYS FEES
CONSTRUCTION LENDING AGENCY
I hereby affirm under penally of penury mat tears a oanstuctbn leldng agency
for me peiomage of the work for ant, this pemd is Issued (Sec 3097 CN C 1
Lenders Name
Lenders Address
I c rtfy that I have read this application and state 1 the above mfamatal is
coned !agree W comply wkh NI cry and to Mws re -
lamp 10 bulldog OnStrUdldn and hereby au t bus
W enter Lupon me m eentoned properly 1
DaleS Aodltant or Mont
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo, CA 90245
SITE ADDRESS -
200ppo Ea Iowasi,4 c t/wy
• �
sLIID NG E�TI
RER
NUMBER
9G aitire' o /
ASSESSOR PARCEL NUMBER
BOOK P805 PARCEL
APPLICANT 1 CON( AC I PERSON
MAARTe N evEv{ssfK
DATE
en-Of-03
ADDRESS arE zee
Wes S4M sation,ea $Lvp
PHONE NO sec
yiri-73/o
CITY
Los AQMGECES
STATE
C4
ZIP
Sootr
PROPERTYOWNER
wRAY t/-IEo&
PHONE NO
ADDRESS
26oa gL. SE sunpo $L✓
CITY
EL SE4UMPC
STATE
e4
ZIP
lot yr
ARCHI fECT
4s a AssociATES
PHONE NO
ADDRESS
/V / S (a C4 R dEY Ave-- s rE me
CRY
WE57Co✓"AMA
STATE
04
ZIP
9/79e
ENGINEER
L.N. N4-.TN4G 1f4ssec
PHONE NO ,o
yYe73/o
ADDRESS
/Onn° 54A/ r4 H04( /C4 Fc(/ v
Los 4MGEce5
STATE
ZIP
9mo Lr
CONTRACTOR��L1j.I�)M���JL'/� /1
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CITYNO
II
AD ES \
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CITY
1-I�LtiI14� lr
STATE
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ZIP 1
5/o1a
PLAN CHECK/PERMIT NUMBER: `$ •
LMP USE•
LLD ANEA
NEW
ID Hti7
ES%E AL
LMP USE
it it AREA
AMNION
MEHCIAL
DMPUSE BLUR AHtA
ALI ELIAIILrt11
DESCRIPTaNOFWORK
CL/4N/Cfnc 4/A44.S
X
Teo
SC1F h ccs
REF II
(Y`r, GROUPCSI
EIS) OFCONSTRtJCTIOr
SQUARE FOOTAGE
NO OF
STORIES
FIRE SPRINKLERS
YES NO
STATTISTI Cj.A )FICATIOr
UNITIS)
OOOE/II EF T
(/1 � L�/fV'J4
$ /'`cco
PLAN CHECK FEE
' /i y
S ��'[` r
VALUATION
ENERGY
,1�1
�J3/A
PLAN CHECK
/
Zi 9iN��
9....L.
VVV
S' 6 V -
IITALL,
1S y1 '
DI I1 f l I4
S
PLAN CHECK FEE
S
REVISED VALUATION
ENERGY
PLAN CHECK
S
RECEIPT NUMBER
INITIALS
DALE
C](//.
PERMIT FEE $ 160 ,••�`.�/�(//�/ —
7ARETENTION FEE S • ( /--+"
SMIP FEE S 0
ACCELERATED FEE S
/Vj�
TOTAL BUILDING PERMIT FEE S k-c o 1 /7
1 I SCHOOL FEES PAID _ HEALTH DEPT APPROVAL
SANITATION DIST PAID FIRE DEPT APPROVAL
'�-
I-1 PUBLIC WORKS FEES PD I— I SCAOMD APPROVAL =w'
�..
r—I OSHA PERMIT OBTAINEDr� INDUSTRAL WASTE APPROVAL
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NO
INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
81
Location and a lbadr
B2
BOIS Engineers Appovl
83
Foundation/Trench forms
84
Snaaural conrale ebb on wade
85
Raised for framing
BB
Under fluor enWton
B7
Furst level Bar sheamng
BB
Second level Boorsheaeng
89
TMd level Boor sheaths -mg
B10
Roof sheatlrg
011
Concrete UOdt
1st Gnut all
2nd Grout RI
3rd Grout MI
cos Grout WI
B12
Seel Inning
B13
Fee Dept frame Inspect/on
B14
Butang Dept frame NspecWt
BI5
Fire somber hangers
816
InsubtoMwathr stnppng
017
Intoner to h and/or *weal
818
Extenor lath
B19
Rated loorCetng assemblies
820
Rated veal assrMYea
1321
Rated exurb reaction
B22
Rated Shan construbon
023
Tatar beings
824
Lotdanage
825
Planning Depl Approval
B26
Fre Dept Approval
021
Public Works Dept Approval
820
Final Budding nspect= approval
DESCRIBE COMPLETELY THE INTENDED USE OF ALL SPACE APPLICABLE TO THIS BUILDING PERMIT
The following statement must be signed by the Building owner
(MB7hen approved by the Buoying OB3ca4 Mae olanees agent may sign for permits other flan the InMlal or shall building permit
wilt the applcant or Mee buflig occupant handle a hazard us material or nature containing a hazardous mate al equal to or greater than the amain
speohed on be hazardous matrlah Memnon pude'I Yes or Na pal
e the anseer to be Wasum des yes viol me proposed butting or meddled batty be wean 1000 feet of the outer boundary Of a sager?
Yes or NO foul
I have read the hazardous malarial Information guide and Use SCAGIA permitting chedesl I understand my requitement under Me Sale of CaMrnb
Heath and Safety Code Section 25505 25533 and 25634 concerning hazardous naterals reporting Yes or No roue
NAME SIGNATURE
INSPECTION NOTES: