1149-02 - 222 IMPERIAL HWY E R9Dais- /31
X
VERSION 12-2000
OWNER
I hereby affirm under penally of
License Law tor the lotlwano reason
-BUILDER DECLARATION
penury that I am exempt from the Connectors
(Sec toil 5 Business and Professions Code
a permit to consaud Mar Improve demolish. or
Any city or county which regimes
radar env strums. prior to as issuance
to llle erected d statement that he
Contractors License Law (Chapter
Business ad Professions Coder
for Me alleged exaryedn My violation
suEoxb the amacnl to a av0 penaltynot
I
also rewires Use appaznt for suds perm I
or she s Revised pursuant to the damsons of the
9 (commenting with Sec 7000) of ON 3 of the
or that he or she is exempt therefrom and me oasis
of Sec 7031 5 by any applicant for a peens
of nmore than five hundred dollars (S500) )
or my employees with wages as their sole rem
structure is not Mended or offered for sale (Sec
Code The Contractors License law does not
bulds Or oldens thereon and who does suds
Ns or ha wen employees provided that such
offered for sale If however the budding a im-
Of rSrtWmar me awneroudder win nave the
de not bold Or mawe to me purpose or sae I
am exclusively contracting with licensed on
7044 Business and Professions Cede The
apply 10 an Owner Of adoerte do builds of m-
foe such projects with a mnbada(s) license
as wear of the Weeny
pensabon rib do the work end the
7044, Business orb Profession
apply wan wear of property Mho
work himself or herself or though
improvements are and intended a
provement is and warn one yea
Ierdar of promo that he a the
InEiI as owner el the properly
rs to construct Me project (Sec
Connectors license Law does not
enses t eren and who contracts
pursuant to the Clnoactors License
Law )
• I am exempt under Section
B VP C to Its reason
Date Stonature of Owner
LICENSED CONTRACTORS DECLARATION
I hereby aeon under penalty of penury Mat I am licensed under prows.ns of
Chapter 9 (commencing with Section 7000) of Drwsin 3 of the Business and
Professions Code and my license la In tun once and meth /� /�a��
• e0(al .i Z J
pira on to
'AleO1license Class Yf�ti/ A bows I`- ber m a rebate
'Alec�f
SgnaMe of Contractor -
WORKERS COMPENSATION
I hereby Ohm under penally of
133.1 have arid will maintain a
compensation as provided for by
of the wadi for Mich tee
Inn and will mani. workers
of Vie Labor Lode -Milne
IS My workers compesabon
Garner STATE
DECLARATION
perjury one of the following declaration 2
certificate of consent to self -insure for
Section 3700 of the Labor Code for the per
permit r ssuad----it-
compensation meurance as required by ) }
Denomance of Me work tor which Ines permit
Insurance camel and polio; number ale
COMP. /NS%TRALE rug
Policy No 044 -e j VAITT 60 I948)
nip sae rare m be mewed
I AI certify Vial in the performance
not employ any pasty m any
compensation laws of California.
workers compensabon provisions
comet' WNI M.WB provisions
13DertC-oz
a 7e pen. . a are tested &Ian WOO w a..)
of the work for which the paint is issued
manner so as to become subject la the workers
and agree II I Shoup become subject to the
of Sec 3 Labor Code I shall inhwlh
``"-
- bate - - - -
WARNING FAILURE
COVERAGE IS UNLAWFUL,
CRIYNAL PENALTIES
THOUSAND DOLLARS
COSMENSA RON. DAMAGES
rue UMOII CODE.
S./nature of Applicant
TO WORMERS CLMPENSA nee
AND SHALL SUBJECT ANEIWLOYER TO
AND CNB ROES UP TO ONE HUNDRED
(511apmA AN ADDITION TO THE COST OF
AS PROVIDED FOR W SECTION 3706 OF
N(TERES T. ANDAI nnaenet a FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of penury that mere Is a construction lending aaeney
for Me performance of the wont for which ass permit Is issued Sec 3097 Cev C I
Lender's Name
Lender's Address
I candy that 1 hare read this appkcabm and stale that the above Infoematon Is
correct I agree to comply with all city and • y ordinances and state laws re
wing to bussing construction and her .•. a - representatives of this city
to enter upon the above -men • ,, bonb
13L-O7. llliLr a.roxe
Dale - ianatae M Applicant or Aped
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY ECONOMIC 8 DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo CA 90245
SNE ADDRESS
22z2-, , IMPl * - *t.&* -r
Ft. aro 9 oaq -
SURE I IDENTIFYING NUMBER
f3Lc R-9
ASSESSOR PARCEL NUMBER �q
00041 � j, Co PAGE V V S FUKII 0 33
APPLICAM IC NTACT PERSON
J .C. CellesS G &
k�-{ 't$JT� k!-' -
V
DATE
' 2 -D L
LI -I
ADDRESS •'
3G7 vAT.t N z 44
PHONE NO
Qc92i 7
CITY
Telta*Nc -
STATE
CS3b—
ZIP
9 t COI
PROPERTY OWNER
Isar TwF-csrJ
PHONE NO
ADDRESS
E /
,,,le,); L;I1 I
CITY 1
i
STATE ,
ZIP
ARCHITECT - v
4 • c UI t ICAM°e44TIP;
PONE NO
�1E092.I1741
ADDRESS
7 vitolaGros var
CITY
T o cu-k vie
STATE
CA-
ZIP
1 ere I
ENGINEER
PHONE NO
ADDRESS
CITY`
STATE
ZIP
0CpF1TRACTORS NAME
ARMS/7 ("SWc7 Ulf
CRY EtC NO
1>9Z 7
PHOEIE NO
6,O g -16 *73
ADDRESS
7 7OS S e SE le°
CITY
164OlKCa
STATE
chi
ZIP
*SO /
PLAN CHECK/PERMIT NUMBER / I qg
-0 el;
CMP USE
BLDG AREA
NEW
RECIOENTIAL
LMP USE
NLOG AREA
ADDITION
C01.RRCIAL
LMP USE BLOC AN) A
It rEFISeN
LESCRIPTION 0 WORK
X N pg/t w rt4 a,n�P carat
c t L to C..-& P j- ki-n % • • 5
A
REF a
on GROUPIE)
Bt F. - I
TYPE(S)OF CONSTRUCTIOt
1
SQUARE FOOTAGE
!/O IS 5F•
NO OF STORIES
FIRE SPRINKLERS
S_ MO
STATISTIC ClAS51F ICATIO!
UNIi19
Jh _7OCT /
/an,
4 r/0/��307/cv
/ PIAN CHECK FTI
. (�
5
vAl TION
ENERGY PLAN CHECK
4 33 5 I�'7��
NEl.EyTllLlFj@E H_ /�
/�j L/fi•
INITIAL
OAj� /I SQ- I Z
5 PILAANNNN CHECK i FE
5/I
REVISED VALUATION
ENERGY PLAN CHECK
S
RECEIPT NUMBER
INITIALS
DALE
a.1 /e��/
PERMIT FEE $ 3It'•`�•Ty-//e�/Y
•''�
/// RETENTION FEE 4 / / 5
f�
SMIP FEE _) 4 / ar�
ACCELERATED FEE (J� S-//r
TOTAL BUILDING PERMIT FEE $ I w! e.^1
a
a
I I SCHOOL FEES PAID I= HEALTH DEPT APPROVAL
M. SANITATION DIST PAID MS FIRE DEPT APPROVAL
[-1 PUBLIC WORKS FEES PD I—'-1 SCAOMD APPROVAL
jJ OSHA PERMIT OBTAINED rl INDUSTRIAL WASTE APPROVAL
RECE T U BEF':
V
INITIAL
se 4'-7
DATE
.( 13-al
i INALF 8
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0
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MD
INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
BI
Locaber, and seeds
r
B2
Bole Engnw. Approval
B3
FoaWmn'r,eneh Wnd
er
Sbuobsal concrete Slab on Owe
115,
Rased Ear bambg
0$
Under Poornnstatbn
137
Fret bevel Boa shgNag
BB
Second level Sow sheathing
09
Third level boor ehaat rg
1310
Roof sheathng
B11
Grimm block
ID Grout eft
End Grad m - -
3rd Grad Id
em Grew Bl
1312
Steel training
S13
Fey Deg frame inspection
B14
Butane Deptbamenspecem
B15
Fire spmM,hangers
BIG
msulabonMeama sbjpitg
B17
Interior lath andla drywall
ale
Ettenr Wm
BID
Rated Poor/Ceding assembes
020
Rated was assannbas
B21
Rated opening protection
e22
Riled
Mao construction
B23
T-0er prongs
$24
La Orange
B25
Planning Deg Approval
B2e
Fre Dept Approval
E127
Pubic Works Dept Approval
13217
FmaI MAIM lespecbpn approval
DESCRIBE COMPLETELY THE INTENDED USE OF ALL SPACE APPLICABLE TO THIS BUILDING PERMIT
The following statement must be signed by the Building owner
Mien approved by the Build rip WERE (be owner% agent may sign for penults other than the Inldal or shell bulkOng permit
We the aspecan1 or Mute puking occupant IWlde a hazardous material or meows conlaufl a hazardous mutual equal M or greater than the amount
speeded on par hazardaH materials nhanabon guWi Yes Of No rnal
If as answer to the waster yes yes ea the proposed addrg a raddled Wray be eNltn t000 teel of the order boundary a a school?
Yes or No Imes
I have mad the hazardous natural inform/bon guide and me SCAOMD pemutnng Nerkbsl I understand my requrement under the Sate of Calome
Health and Safety Cede Serum 25505 25533 and 25634 mncemrg hazardous matenals nwwvuy Yes or No tau,
NAME SIGNATURE
INSPECTION NOTES
\�11i„ U>, 40 SuLra \cur SLAG wog AWe --
nn ,
I 0 \05 li cti imrJ Alta.)
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