1096-02 - 2222 IMPERIAL HWY EVERSION 19a000
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt
License Law to the tottering reason (Sec 70016 Business
My city err molly wtdA requires a permit to construct,
reWV any structure plod to its Issuance also reauam thO
to fie a signed statement that he or she Is bcensed pursuant
Contractors License Law (Chapter 9 (commencing with
sunless and Professors (Opel or mat he or tine Is ex:..:
fir the alleged exeraptot My violation of Sec 7031
su the npllcant to a ail penalty of not more ..
from the Contracture
and Prof. Lode
alter improve ... . sh or
—i . yrm permit
to ,. - provisos of the
Sec %I r) of Div 3 of the
Maardn and the eave
• any applicant for a permit
me hundred domes (9600) I
or offered fa sale (Sac
License Law does not
and who does such
provided that such
the building or kn-
-outlet WE nave to
to the moose of sale I
with licensed an-
Professions Code The
progeny who builds or PM1
a contradols) scone
C for Os reason
u I.mwma of the progeny omY eon... :.withwagesastheirsolecom-
pensaton tell do the wok and the structure not Intended
7044 Business and Professions Code r Contractors
APO/ to an amer of properly who but • - • Improves thereon
himself herself
work a or through her own employees
improvements me not untended or wed for sae If however
provemem is sold within one - - DI wMnplebon'tile owner
burden Cl Droving that he or . ,: did nor rap or lmpray
I as owner of the. ••- amexclusively contracting
trs to construct :.:..Oct (Sec 7060 Busuw ss and
Lantradors License - does not sooty to an owner of
Prows thereon . contrails for such prgeds with
pursuant to the •• tractors License Law )
Dime pt rider Seaton B AP
Date Signature of Owner
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am Scented
Chapter 9 (con nenag with Section 7000) of Division
Profession code and my bane is in mil lace and sect
—1 2
under provisions of
3 of the Business and
7-I-ol
l se Gass umber Expiration Date
10-2')-0 2
Date 'Mature of Contractor
WORKERS' C MPENSATWN DECLARATION
I hereby affirm under penalty of perjury one of the following
Q I have and will maintain a certificate of canal to
compensation as worded for by Sect 3700 of the Labs
dedarat
self -Wore for as
Code Me
as in
work to fa
�e
famance of the work for woad' this permit Is Issued
1 have and aqo maintain wpkere compadat on insurance
Sec TOO of the Labor core for the mrlamance of the
is issued My workers' mpense surer ce crier an
Caroni S t A Al I/
Poba No wvKGl000gl
Om seen n es w be wwlead a M pro Y law. lows ern RIM or Iml
Ul !away that In the performance of the wok for which the permit Is Issued
I not employ any person In any manner so es to become subject to the workers
compensation laws of California and agree 1 A I afoul become subfect to the
comply compensation onso provisions of Sec 3 d� I Na01oNNnth
comply von those anproa
10-2 4-02
bate Signature of Applicant
WARNING FAILURE SECURE WORMERS'COMPENSATION
I COVERAGE ANAI AND SHALL SUBJECTT EMPLOYF_R TO
CROSNAL PENALTIES AND MIL FINES UP TO ONE HUNDRED
THOUSANDDOLLARS(E000). IN AMMON TO THE COST OF
CIMP DAMAGES A AS PROVIDED WON IN SEC DON SIOS OF
IKE LA
THE LABOR COOS INTEREST, AND ATTORNEYS FEES
CONSTRUCTION LENDING AGENCY
I hereby affirm under penally of penury that there Is a construction lending agency
for the performance of the work for which this permit is issued (Sec 3097 Cr, C I
Lender's Name
Lender's Address
I certify that I have Head this appkmton and state that the above infamatan s
aped 1 agree to comply with all city end county ordnance. and state lama s-
lang to bottling constitution and hereby authorize representatives of Vas oty
to enter upon the N%We-mnboned pr 1y for inspection WrD
10-24-02
Oats a Aoobcanl or Adept
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo CA 90245
SITE ADDRESS
L2222 EIm e✓Hl
SUITE / IDENTIFYING NUMBER /
f t Sec whd0 C c
ASSESSOR PARCEL NUfdi
{/'�/(////� /J
000M PAGE / PAn2
APFIdCAfIT /SANTACT PERSON
N� //�LT
-DATE
/0-79-02
ADDRESS
Z 392. Se CC tc man
PHONE NO no
311-705 r
CITY
T^u/inch/e
STATE
Ct
ZIP
SO/O
PROPERTY OWNER
4 7" sG elDRESS
PHONE NO
Ad DR
/
CITY
STATE
ZIP
ARCHITECT
c. Ch47,
PHONE NO
DRESS
CITY
STATE
ZIP
ENGINEER
PHONE NO
ADDRESS
CITY
STATE
ZIP
CONTRAC E
^/'
� .
CITY LIC NO
22'S2
PHONE NO re -
177-709r
MOFtESS - /
23392 /g/emon
`5
j WI. 0h /L
STATE C4
5/O/0
PLAN CHECK/PERMIT NUMBER frog
t (4..0
1L
'_ -
CMP USE Dt. AREA "ESIDENTIAL
NEW
UV US'E i U(. AREA -
ADDITION
COMMERCIAL
LMP USE
AL ERA IIIION/
o_Ul�/s (AREA
LE�,I GWa,- wq I/ O-Ft/CPf cei/i'Ff
eerrs., /KV/4•�,OfY-/• /
/
REF O
OCC G PISI
IYPE(S)OF CONSTRUCTIOF
TYPE 4-
SQUARE FOOTAGE
2 Sri 3
NO OF STORIES
FIRE SPRINKLERS
YES,...) NO
STATISTICAL CLASSIFICATIOI
no2)1
UNITISI
C IN EFFECT
/ q 5 s,
v�v $ J'7 0
`PLAN CHECK FEE $
ENERGY PLAN CHECK $
I q I/ s 19
VALu7ION
•�//
• �� • I I
HECEIP1 NUMBEN
INITIALS
DATE
S
PLAN CHECK FEE S
ENERGY PLAN CHECK $
REVISED VALUATION
RECEIPT NUMBER
I INITIALS
DATE
PERMIT FEE S
// RETENTION FEE S
V� SMIP FEE 'j S
ACCELERATED FEE S
TOTAL BUILDING PERMIT FEE S
la 01,00
/0,10
,3 ' /5
;9 A / r
FEES PAID .
DIST PAID
WORKS FEES PD
PERMIT OBTAINED
APPROVAL
fik •)
APPROVAL
APPROVAL
WASTE APPROVAL
_ SCHOOL
_ HEALTH DEPT
SANITATION
r—J FIRE DEPT
I-1 PUBLIC
r-1 SCAOMD
r—.1 OSHA
r-1 INDUSTRIAL
R IPT
R' a
. _
I INIT A�Sa
�-1C
DADATE ���
FI`� D
1
r.
tit0
NO
INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
81
Location and setbacks '
82
Soars Engneerb Approval
83
Foundation/Trench forms
Bs
Structural mndete slab on grade
85
Rase, low framing
88
tinder floor nslWubn
BY
First level Door sheathing
88
Second level floor sheathing`
60
Thad Mvel floor eleatdtg -
1310
Rod absentia
011
Concrete bloc
Ill Grout 4a
2nd Grout eft
3rd Grout St
in Grout It
B12
Steel baring
B13
Fee Dept crane nspedon
B10
BWblg Dept bane nspecbon
B15
Fee slankler hangers
BIB
Insub4oMwama shppng
B 1 T
Inlenor lath and/or drywall
BIB
Exlaubth
BID
Rated Ma/Cetne assemblies
820
Rated wee essonthes
B21
Rated openng protection
822
Rated shaft construdm
B23
T-bat Goings 1
020
Lotdlanage
B25
Planing Dept Approval
B26
Fre Dept Approval
822
Public Works Dept Approval
B28
Final But4mg inspection approval
DESCRIBE COMPLETELY THE INTENDED USE OF ALL SPACE APPLICABLE TO THIS BUILDING PERMIT
The following statement must be signed by the Building owner
(When approved by the Budding Mid, the owner's agent may sign for permits other than the Initial or shell building permit
WI the appfom or haws Wiring occupant hande a hazardous animal or mature cantering a hazaNan material equal to or greater than to amount
specified on me hazardous matwals information guile? yes or No load
If the answer to to question vas yes MI to proposed Dann ° or modified bctty be *Ann 1000 feel of the outer boundery or a Ichoold
Yes or No loot
I have read the hazardous material Wanabon gude and the SCAOMO pemonmg theddst I understand my requuemenl under the State of California
Heath and Safety Code Section 25505 25533 and 25634 cbncemvq hazardous matenab reporting Yes or No loot
l
NAME SIGNATURE
INSPECTION NOTES.
irl-3o-v2-
Re, ]n100