1083-01 - 2250 IMPERIAL HWY E (4)VERSION 12 2000
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors
License Law for the tdlpxng reason Mee 7031 5 Business
and Professions ..:
My cm or county which requires a permit to construct alter improve demon
repair any structure poor to its issuance also requires me apohme tts - n
to fide a signed statement that he or she is licensed pursuant to the prow sit the
Contractors License Law (Chapter 9 (commencing Sec. 7000) B .
with of 3 of the
Business and Professions Lode) or that he or sine is exempt tier- and the oases
for the alleged exemption My violation of Sec 7031 5 by any -nl for a permit
sup1Ms Me applicant to a awl penally of not mere than five -., ..red dollars (5500) )
LJ I as owner of the pµwRly or my employees with . gas as their WNcon-
pensabon will do the work and the structure is not in - . _. or offered for sale (Sec
7044 Business and Professions Code The Con as License Law does not
apply to an owner of properly who buttes a m. •- thereon and who does such
work himself or herself or through his or her • employees provided Nat such
Improvements are not Intended or offered sale If however the bolding or im-
provement Is sold within one year of ...: -tan Me Owner -builder will have no
burden a proving that he or she did : build or improve for me purpose of sale I
0 I as owner of the property exclusively contracing with licensed con
trades to construct the protect ' - 7044 Business and Professons Code The
L ntradps License Law doe 01 apply to an owne of property Wm builds or an
ports thereon and who .. • acts for such protects with a contractor(s) !tense
pursuant to the Contras.._ License Law )
lam exempt . r Section B BP C for this reason
Date' Si nalum of Owner
LICENSED CONTRACTORS
I hereby affirm under penally of perjury that 1 am
Chapter 9 (commencing with Section 7000) of Division
Professions Code ma my license is in tun tow
, J 5 L
DECLARATION
licensed under provisions of
3 o1 the Business and
and en:.
;" I j2Joz
Clasli
Date
RLicense
I�/h �A
1
rat
-• • re
to \ gnats- � I • recta
WORKERS'
I hereby affirm under penalty
I have and will maintain
compensabort as provided
to nonce of the work for which
lin I have and will maintain
ber37110 of IV LewOw Lode
is issued My workers compensation
XCame 53
COMPENSATION
of
a certificate
for by
this
workers
to the
[ L7
DECLARATION
penury one of the Meowing declarations
of consent to self insure for as
Sedan 3700 of the Labor Code for
permit is issued
wrnpensabw insurance as
pMpmance of the work Ia Much this it
insurance earner and number are
e la
] pest
Perry No 1 A� ( C I
�oTa6
(rir teem reed u�
I 61 I certify that in the performance of the work for
not employ any person in any manner so as to
compensator laws of California and that d I
workers compensation provisions of S 00 of I :
Ph win those ppNsans
ri(/X
nth �r OhWha wvl
which his persist is issued
become subject to the workers
yy.•,, •• e subject to the
L ... I shall forthwith
i
JIte
Vale t.
WARNING FAILURE ro SECURE WORKERS
COVERAGE IS UNLAWFUL- AND SHALL SUBJECT
CRININAL PENALTIES AND OWL FINES UP
THOUSAND DOLLARS MOO 000) IN ADDITION
COe®ENS*TION DAMAGES AS PROVIDED FOR
ME LABOR CODA WIERES7. AND A
. Iwf
COMPENSA PION
AN EMPLOYER TO
TO ONE HUNDRED
TO THE COST OF
IN SEC NON lies OF
RORNEYB FEES
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of penury that there Is a construction lending agney
for the performance of no work for which eras permit is issued (Sec 3097 Cry C )
Lender's Name
Lender's Address
I ceOAy that I have read ores applto
correct I agree to comply with all dry .
lated tobeading wnspitlen and her.
od.
o enter upon thea Mna
�,
J
slat
-• my
i .
f. inI
that a • e info nano Is
.. - sus • • state laws re-
r p.-.la aMIS Oty
.—
-
' tama-
\
VI
le !` • . Wrre of •.... to Agent
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo, CA 90245
SITE ADDRESS
22S'1° /Alfit icair .v/a,stemy
UI E / IDENTIFYING NUMBER
AS5 5-SOR PARCEL NUMBER
BOOK PAGE PARCEL
APPLICANTf CONTACT PERSON
send -cc,
TDA I E
PHONE NO
To-.207
— 44 3e
ADDRESS
20ceo Illetw.o-Cos% Ava
CITY
Los 4.cats
STATE
OA
ZIP
9 oozf
PROPERTY OWNER
/try
PHONE NO
ADDRESS/c
CITY
STATE
ZIP
ARCHITECT
PHONE NO
ADDRESS
CITY
STATE
ZIP
ENGINEER
PHONE NO
ADDRESS
CI1Y
STATE
ZIP
CONTRACTORS NAME
nzL GnA4,4—:
CITTTYLILIC NN'`OADD
SS
1 ILt b6wl +C P L
CITY
&r&kat IA-
STATE
iI Ca .
ZIP
C1 %3441
PLAN CHECK/PERMIT NUMBER I�I
LMP USE
BLDG AREA
NEW
t SIUE I
CMP USE
BLDG AREA
ADDITION
NMERCIAL
JC.
LA1P USE
DG AHEA
ALf EHA
DESCRIPTIONO WORK
)( XL€co 4iv,t.c,A4e, Oise, 0A0
GQmF ( R ?lime— )
REF
OCC�tOUP(S)
TYPEIS) OF CONSfRUCTIOI
SQUARE FOOTAGE
NO OOFF STORIES
FIRE SPRINKLERS
YES NO
STATISTIC/yCLAS FICATIOf
No
UNIT(S)
COOL 7 FIT
COMMIT
xis, eoo PAN CHECK FEE
f / 'u'
V UATION
ENERGY PLAN CHECK
4
H}_[.EIPT NUM EH 1 ) -
/�
ly�/��. J�
INw! C./
DATE/ O/2 /O /
4 PLAN CHECK FEE
$
REVISED VALUATION
ENERGY PLAN CHECK
S
RECEIPT NUMBER
I INITIALS
DATE
s�T-ly./}1In co
PERMIT FEE S _ 1
%n� /�(Y
'3 I) J RETENTION FEE 4 1 ' w
SNIP FEE f tr
ACCELERATED FEE S er---
TOTAL BUILDING PERMIT FEE 4 /Jf.51 s 3c /
_
SCHOOL FEES PAID _
HEALTH DEPT APPROVAL
OM SANITATION DIST PAID FIRE DEPT APPROVAL
C ] PUBLIC WORKS FEES PD (-1 SCAOMO APPROVAL
r—I051tA PERMrtkIT OBTAINED j- INDUSTR AL WASTE APPROVAL
•FP
cE/
INITIALS
yr-1
VLI
1//JO
DATE
I id
61
co
-o
r
^^Z
m
r
ci
0
NO
INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
BI
Location and setbacks
02
Sods Engineer's Approval
B3
Foundaeon/Trencw terms
Bs
Structural concrete slab on grade
B5
Raised floor framing
88
Under Moor insulation
B?
Forst level floor sheathing
B6
Second level floor sheathing
69
Third level Root sheaeimg
810
Roof sheathing
B11
Concrete block
'-
1st Grout at
2no Grout Mt
3rd Gout eft —
am Grout II
1512
Steel framing
613
Fire Dept frame mspectan
614
Budding Dept fame nspecuon
B15
Fee sprinkler hangers
BIS
msuatmAveamer stepping
B I I
Intenor tam and/or drywall
Bib
Eslenor lath ‘ 1
t,
0IS
Rated floor/Ceiling assemblies
132O
Rated was assemblies
021
Rated opening protection
B22
Rated shaft construction 11
B23
T-bar ceilings
624
Lot drainage
B25
Panning Dept Approval
B26
Fore Dept Approval
621
Public Works Dept Approval
B26
Final Budding nspecion 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 Building Official the owner's agent may sign for permits other than the Initial or shell betiding permit
Win the applicant or future budding occupant handle a hazardous material or muture conning a hazardous material equal to or greater than the amount
spooned on the hazardous rnaterats ntomutaon guide? Yes or No tool
11 me answer to the question was yes M the proposed building or mod fled faddy be mNm 1000 feet 01 the Outer boundary of a school?
Yes or NO leer
I have read the hazardous material Information guide and me SCAOMD portmtW{ checklist I understand my requcement under the Sate of California
Health and Safety Code Section 25505 25533 and 25634 concerning hazardous materials reporting Yes or No lull,
•
NAME - SIGNATURE
INSPECTION NOTES
R. 1/3100