1152-02 - 2222 IMPERIAL HWY E R9 (3)4
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of penury that I am exempt from the Contractors
innse Law tar me t000Mrto reason (Sec. /W 15 Business end Pretessrons Lode
My any or county which requires a permit to construct attar improve demolish or
repzr any structure prior to Its Issuance also reglees the applicant for such pemle
to he a signed statement Nat he or she us licensed pursuant to the provisions of the
Contractors License Lew (Chapter 9 (commencing with Sec 7000) of Div 3 of the
Business and Pmtessiols Code) or mat he or she is exempt therefrom and tM bass
for the alleged exemption Any violation of Sec 7031 5 by any applicant for a permit
sueds the applicant to a cad penalty of nol more than five hundred delete ($500) )
I as 'owner of the property or my employees with wages as thee- ado wn-
pensators we do the work and the structure Is not intended or offered for sale (Sec
7044 Business and Professions Code The Contractors License Law does not
apply to an owner of property who builds or Improves thereon and who does Rich
work tensed or herself or through Ns or her Own employees provided that suds
improvements are not mended or offered for sale II however the budding or im-
provement its sold within one year of completion the owner-0elder will have the
burden of prang that he or she did not build or mprove for the purpose of sale )
I�I I as owner of the property am exdusvey contracting with licensed coo-
t ore to construe the project (Sec 7044 Business and Professions Code The
Contractors License Law does not apply to an owner of property who builds or Ice
proves thereon and who contracts for sudi projects with a contractors) licensee
pursuant to the Contractors License Law )
I am exempt Section
under B aP L. to Ins reason
Date Signature of Owner
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty Cl perjury tut I an licensed under provisions of
Chapter 9 (menenog with Section 7000) of Division 3 of the Business and
Prolessions (ode and my license is In we tome and effect
/5-( i/ 2 y 7-M1
License Class Nun, Emraton Date
(l - /3-air
Date of Contractor
WORKERS C SATION DECLARATION
I hereby affirm under penally of one of the following declarations
III I have and will maintain a to of consent to sellinsure for work IL
compensation as provided for by Section 3700 of the Labor Code for the per /
1 of the wok lot which bus permit ts issued
I have and will maaitail workers anpesabal insurance as renaed tic
of the Labor Code for the performance of the work for which INs permit
is workers compensation insurance ia7y and policy number are
Carnet + fie-4 /
nt
policy No viUKG( acoy/
tie r.tiai Mild rot a mrpxMa in p.m* Straw Mesa dollars NKendteal
I 21I certify that in the performance of the work for which Was permit is issued
not employ any person In any Tame so as to become subject to the workers
campensahon laws of Caillama and agree that d I should become subject to the
waken compensation provisions of Sec 3700 a Labor Code I shag forthwith
comply with Ouse provisions
//-/1-c7--
Date' of Applicant
WARNING FAILURE TO SEC 3 COePEN3A TON
COVERAGE IS UNLAWFUL HALL SUBJECT AN EMPLOYER TO
CRINIALAL PENALTIES AN CML RUES UP !DONE HUNDRED
THOUSAND DOLLARS (3f00000), INADOONIN TO THE Cos? OF
Cn1RFAMATIOIE DAMAGES AS PROVED FOR W SECTION lee OF
PIE LABOR COOS WTEREs7, AND ATTORNEY" FEES
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of penury that there Is a construction lending agency
for the performance of the wok for which INs permit Is Issued (Sec 3097 Cry C )
Lender's Name
Lede's Address
I certify that I have read this application and elate that the above information Is
correct I agree to comply with all ay and county ordinances and state laws re-
lating to balding alnsbucton and hereby ze rein Wes d ws ore
to enter upon the above -mentioned for in Purposes
/-/7-at-
Caro a of Aopllcant or Agent
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo, CA 90245
SIZE ADDRESS
1.22 z E r l M pSi2 4 fit f+w y
SUITE 7 IDENTIFYING NUMBER
.F3I-v4> R - R
ADUIt IONAL INFORMATION / LEGAL DESCRIPTION
ASSESSOR PARCEL NUMBER
e136 RaE 005 P o3BOOK 3
APPLICANT I CONTACT PERSON
C
PHONE NO
&so) *to-2r)t
FAX N J
31.),5,2-I -0212
PROPERTY OWNER
R-hy1+taorf
PHONE NO
ADDRESS
CITY
STATE
ZIP
ARCHITECT
6/u- K/ M 4 A
3° c-
PHONE NO
,
44g0-2-1�7+-
ADDRESS
z$ 616? ✓l Sit- enAD6R-4
CITY
STATE
C4k-
ZIP
Crav7r
/Li✓
ENGINEER -
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-
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PHONE NO
ADDRESS
CITY
STATE
ZIP
CO RACTORS NAME
AJG •
PHONE NO
313-DDSs
AD ESS
2 3 9 2 S a, -te ran , L., F ire
CITY //
Trail v70la /t
STATE
C4
ZIP
9toi O
PLAN CHECK/PERMIT NUMBER // _0 7--
ZAP USE
BLU(• AREA
NEW
TESIDENTIAL
CAP USE
ttLDG AREA
ADDITION
tOMMElli
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LMP USE
taLUl• AREA
rNAIIUN?X
DESCRIPTION 0 WORK
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RECEIPT ENERGY PLAN CHECK s
• ADDITIONAL FEE S
REVISED vuwtaN
RECEIPT AUDI IIONAL ENERGY s
L� 1•
RECEIPT PERMIT FEE S OW 0
RETENTION FEE S I I. 5 a
L SMIP FEE sS L I I
(OTHER) S
TOTAL BUILDING PERMIT FEE S ''%V' 2- 3 ail
• I if
r-I SCHOOL FEES PAID 1---1 HEALTH DEPT APPROVAL
_
SANITATION DIST PAID _
FIRE DEPT APPAL
PUBLIC WORKS FEES PD SCAOMD APPROVAL
r i OSHA PERMIT OBTAINED M INDUSTRIAL WASTE APPROVAL
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NO
INSPECTION
I DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
81
Location and setbacks
82
Sods Engineer's Approval
83
Foundation/Trench fans
B9
St'uciu,al concrete stab on grade
B5
Raised floorhamsg
B6
Under floor nsulalzn
BT
Fnst level floor sheathing
B8
Second level floor shoal/dog
B9
Third level flax sheathing
B10
Roof sheathing
B11
Concrete block
" t - t
1st Grout lift
2nd Grout kft
t
3rd Grout eft
4th Grout lift
B12
Steel framing
B13
Fee Dept frame nspecbon
B14
Budding Dept frame Inspects n
1315
Fee sonnet( hangers
016
Insutatnweather stripping
817
Mterer lath and/or drywall
B18
Ertersr lath
B19
Rated floor/Ceding assemblies
B20
Rated wall assemblies
B21
Rated opening protection
B22
Rated shaft c nseuclnn
B23
T-bar ceilings
B24
Lot drainage
B25
Planing Dept Approval
826
Fee Dept Approval
827
Public Works Dept Approval
828
Final Binding 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 lb. Bending Official, the owner's agent may sign for permits other than the haldal or shell Wilding permit
Will the applicant or future budding occupant handle a hazardous malenal or mixture containing a hazardous material equal t0 or greater than the amount
specified on the hazardous materials Information guide? Yes or NO ta.a.l
d the answer to the quesoon sea yes wts the proposed addssg or modified lately be wNun 1000 feet of the cuter boundary of a school'?
Yes or No tone
I have read the hazardous material nfonnaton guide and the SCAOMD permitting thecldisl I understand my requirement under the State of Catania
Health and Safety Code Scram 25505 25533 and 25634 mwenwg hazardous rretenats rewiring Yes or No tenth
NAME ' SIGNATURE
' INSPECTION NOTES.
w. rntos
Cty O/e/sequicio
DEPARTMENT OF PLANNING
AND BUILDING SAFETY
350 Main Street
El Segundo, CA 90245
Phone: (310) 322.4670
Fax: (310) 322-4167
DEMOLITION DISCLOSURE FORM
PROJECT ADDRESS: 7iz zZ e-
- - -PERMIT NO.: //5j a - D J-
Effective January 1, 1991, Assembly !El 2791 requires applicants for demolition permits to comply
with certain Environmental Protection Agency (EPA) and South Coast Air Quality Management
District (SCAQMD) regulations concerning asbestos containing materials. (SCAQMD Hotline (909)
396-2336).
The following questions must be answered before your application for a demolition permit can be
processed.
1. Have you complied with the requirements of the South Coast Air Quality Management
Dider Rule 1403?
( V \ YES (� 0 - Follow SCAQMD notification procedures`
Z. is the structure asbestos free? ( you are uncertain, you should contact an asbestos
consu to investigate the , = before answering this question).
( ) YES ( %% 0 - Follow SCAQMD notification procedures'
3. Does the proposed demolition affect less than 100 square feet of asbestos containing
material?
( 5YES
(*) See rev
Signatur
( ) NO - Follow SCAQMD notification procedures*
rse for S s QMD n
Tel4" Styr -�
Print Name
( _,)-Owner
( ) Contractor
( ) Architect
( ) Authorized Agent
cation procedures.
//-/7 -° 2--
Date