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1103-01 - 2250 IMPERIAL HWY E (3)A VERSION 12-2000 OWNER -BUILDER DECLARATION I hereby affirm under penalty of poryry that I an exempt from the Contractors License Law tar the tdewno reason (Sec 1a1 b Business and Professions Code Any city or county whldh requires a permit to construct alter Improve demolish or taper any structure Dna to as issuance also requires the applicant tor such to file a signed statement that he or she is licensed pursuant to the the Contractors License Law (Chapter 9 (commencing with Sec 7E00) of of the Business and Professions Code) or that he or trio is exempt there and the basis for the ateged exemption Any wdabon of Sec 7031 5 by any I for a permit ads the applicant to a oW penalty of not more than Elie dollars ($500) I ' i I as owner of the property a my employees with as thew sole com- pensation we do the Mork and the structure Is not int ed or offered for sale (Sec 7044 Business and Professions Code The Con License Law does not apply to an owner of progeny who builds or thereon, and who does sudl work himself or herself or Vvogh his or her employees provided that oath wnpovanents are not intended or offered sate II however the building or rn- proveineni is solo mewl ale year at non the dmla-0InMe we have Use burden of promo that he or she did build or improve to the purpose a sale 1 Q I as owner of Lie propen exclusively contracting with licensed urn tractors to construct the prq Tax Business and Prof essons Code The Contractors License Law s not awry to an owner or property who builds or In Proves thereon and tracts for such prgects with a contrador(s) kcense pursuant to the ors License Law ) I. I am er under Section B IP C for this reason Date Signature of Owner LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of ki Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prole s Lode and my license is en tub face and coed 223/ //-0/ License tyro Date xoratmn / Ir/ �Si L� Dateee atura/ of Contractor WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations Q I have and well maintain a certificate of consent to sell insure for week compensation as provided for by Section 3700 of the Labor Code for the per t form the work for whir this permit is Issued have are we maintain workers compensation insurance as required a Sec 3/1/0 of the Labor (ode to the performance a me work fur which this 91ssued My workers compensation msur Ca and Palmy number are Comer P /*J\ Policy No 71 r Ism to iwwi Iss=moedM seen eb pyeetl:m wAvr 0iD3le saai rj I certify that In the performance of the wok to which this is issued permit I 0ll not employ any person m any manner so as to become subled to the wakes compensation laves of California and agree that it I should become aged to the workers compensation of Sec ofDye Labor Code Mall wondv with compthose IXrnnsm /II/^_�_�. p 4 q Date Signature of Applicant WARNING FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES U➢ TO ONE HUNDRED THOUSAND DOLLARS (shoo 000) IN ADDITION TO THE COST OF COMPENSATION DAMAGES AS PROVIDED FOR RISECIION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEEL CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of penury that there is a construction lending cv for the performance of the work for which this permit Is issued (Sec v C ) Lender's Name Lenders Address �/ I certify that I have application and sla hat the above inform alen e erg oty tuned !agree t with a and •. - and state laws re - construct hereby •au •• •��senWaves of this city • rpose / ( Date Sienae ol•••Cant aMeal BUILDING PERMIT BUILDING SAFETY DIVISION COMMUNRY ECONOMIC B DEVELOPMENT SERVICES DEPARTMENT 350 Main Street El Segundo, CA 90245 InwoeHion Reme➢sLLine.131015: SITE ADDRESS ZZJV CJ MQt a�L/hnf SUITE I IDENTIFYING NUMB ASSESSOR PARCH. NUMBER BOOK PAGE PARCEL ICANT/CONTACT PE?pN aA0e 11 r ergo,-» "DATE /n 1.1,-OI ADDRESS --�� 1658 �/�/�l �EL(w Il oo7 r ONE NO £Bi-3gz0 TV / �is ///��Ra y. /1 t (/,/1.'d// STATE (M ZIIPy/nJJ(y��/I 3 R b r lER- e l V PHONE 9j r yo AD RESS ziso 6 ea)nL/fnot aCITYjog ri +' fa) S/T/�/AJ�/Ts/E(/ / F L t ZIP WJ P2ENO ADDRESS CITY STATE ZIP ENGINEER PHONE NO ADDRESS CITY STATE ZIP CONTRACTORS ' 6/2O4 CITY LIC NO gi 2 22/1 TMTMG�� �-��/TL /fa'v/�/'�QT M� VJL/1/ d 51 PHONE N j 1Bzt. �%f18 2/o!/v<i PLAN CHECK/PERMIT NUMBER 11 o3--0 I 1 US'E LMP BLOG AREA NEW RESIDENTIAL LMP USE BLOta AREA Atwlrl(NJ (AMMUNCIAL LMP USE BLDG AREA ALIENATION DES wOL i. Ait145r fl*o&r AMItOVJ $ `5 »°" 1f , R p OCC GROUP PE(S)OF CONSIRUCTIOf SQUARE FOOTAGE NO OF STORIES FIRE SPRINKLERS YES NO STATISTICAL CLASSIFICATIO lea UNITIS) CODE IN EFFECT aJ O PLAN CHECK FEE S NALUATION ENERGY PLAN CHECK S RECEIPT NUMBER INITIALS UAIE S PLAN CHECK FEE S REVISED VALUATION ENERGY PLAN CHECK S RECEIPT NUMBER INNIAL5 DATE PERMIT FEE $ 41• RETENT ION FEE S 5 O SNIP FEE S ACCELERATED FEE TOTAL BUILDING PERMIT FEE S • I ) SCHOOL FEES PAID _ HEALTH DEPT APPROVAL I—J SANITATION DIST PAID FIRE DEPT APPROVAL (--1 PUBLIC WORKS FEES PD (--, SCA MD APPROVAL 1--1 OSHA PERMIT OBTAINS U R AL WA TE APPRO PTNU � INITI 5 ` DA 0k SINAI. BY n DAI��VS b\ NO INSPECTION DATE INSPECTOR REQUIRED BUILDING INSPECTIONS AND APPROVALS al Location and setbacks -- 82 Sods Engineers Approval B3 FdundatiordTrendt forms Ba Structural concrete slab on grade B5 Raised floor framing tie under floor insulation — BT First level floor sheathing B8 Second level floor sheathing B9 Third level Boor sheadung BIB Roof sheathing 811 Concrete block 1st Grout lift 2nd Grout il 3rd Grout e t am Grout kB B12 Steel training B13 Fee Dept Name inspection 814 Budding Dept (lame inspection B15 Fee sprinkler hangers B16 Insulation/weather stnppng B17 Intenor lam and/or drywall BIB Ertenor lath Big Rated floor/Ceding assemblies 620 Rated wall assemblies B21 Rated opening protection 022 Rated span construction B23 T bar ceilings B24 Lotdrainage 825 Planning Dept Approval 826 Fee Dept Approval B27 Public Works Dept Approsal B28 Final Budding inspection approval DESCRIBE COMPLETELY THE INTENDED USE OF ALL SPACE APPUCABLE TO THIS BUILDING PERMIT The following statement must be signed by the Building owner (When approved by the Building Official the owners agent may sign for permits other than the Initial or shell building dentin Win the applicant or future budding occupant handle a hazardous matenal or mixture containing a hazardous matenal equal to or greater than the amount specified on the hazardous matenals Nlomation guide, Yes or No tent II the anther to the question wa5 yes ins the proposed b ildng or netted facility be wow, thou feet of the outer boundary of a sdiod' Yes or No twain I have read Me hazardous nitdNt information guide and me SCAOMD permitting dted35t I understand my requirement under the Stale of Cal Iornla Health and Solely Code Section 25505 25533 and 25634 concerning hazardous materials reporting Yes or No tool NAME SIGNATURE INSPECTION NOTES.