1081-99 - 2260 IMPERIAL HWY E (3)a/70 Slimier/iv
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APPLICANT A i
CAS lJlYi
ADDRESS
Aar S. 44/PU4y v #vot
CITY.45yr ZIP PHON 6
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NAME-
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ADDRESS - PHONE
CITY STATEJZIP
ARCHITECT
NAME de if 2GOG
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ADORE PHONE
CITY STATE/ZIP
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NAME
ADDRESS PHONE
CITY STATE/ZIP
,WORKERS' COMPENSATION I CONTRACTOR
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NAME15/B �ii/IP/L•„ aid t,.0
MAILING ADDRESS'
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CITY/ -I i1/9A,7 J
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FetP T: nit
ZIP9
STATEr w
720
CITY LIC NOgO9r
I hereby aahem under penalty y of penury that I am lksnnd a provisions 01 Chapter 9
(commuting with Seddon 7000) of !Won 3 of the Busmen and Professions Code and
my bdenseatin Ng htge qd effect 9 /
License Class / Ix No F�yG
�P•
S
Date /1 Z /- f r Contr Signature
WORKER'S COMPENSATION
I hereby ahem under penalty of perjury one M
I have and will msnleb a certificate al consent
DECLAR ON
the following declarations
to se0•Insute for worker
of me Labor Code far the n
asmpenaabon, as provided for by Section 3700
tee this
work which permit is issued
01
have end will maintain workers compensation Insurance as required by Section
3700 of theLaborLabor Code, for the performance d the work for wwluch ens permn re issued
1pimpertemben Insuferlo comerand
Comer t CAR`% N
�bern=" 77 net N%
(This eemon need not be completed a the perms is for one hundred dollars (S100) or leas
- I minty Dal In the performance of the work for which this permit a Issued I shall not
employ any person In any manner so 5310 become suggest to the workers campenesbon
Laws of California end agree mat III should become su0pet to the workers compensation
provisions M Section 3700 of the Labor Code I shall lormwit com
oate /11 HI 5ro nabs -
WARNING Failure te segue workers compensation age Is unlawful and shall
subpa an employer t0 cnminal penalties and civil lines up to one hundred thousand
dollars ($100 000) in addition to me cost at compensation damages as provided for in
Section 3708 of me Labor Code Interest and enomey s lees
W_
rti
W
3
C
I herby affirm under penalty M perjury that I
for the following reason (See 7031 5 Business
when t.Rudn a puma to construct sitar improve
Io its issuance also requires Me applicant for
Or she is licensed pursuant to the prOVISIOne
(commencing the Section 7000) of Division 3
that he or she u exempt therefrom and the basis
al Season 7031 5 by any applicant tor a nun
not more than Iva hundred dollars (S500)) )
() I es owner d the properly or my employees
do the work and the structure is net intended
Proleuhna Code) The Contractors License
who twigs Or Improves thereon end who does
employees provided mat such Improvemen.
however the building or improvement Is •
Mal wall have me burden ol pray -I he
purpose of sale)
( ) I as owner of the pro • -- am exclusively
construct the project ( 7044 Business
License Law doe, • gayly man Owner of property
who contract; - such projects with a contracogs)
License a under
() a � *mot uer Se[_ B 6 PC for this
ant exempt tram the Contractors License Law
and Prolesslons Code) Any city of county
demollch or raptor any structure pnor
such nand to eh a signed statement that he
of Irk Contractor License Law (Chap 9
of the Business and Professions Code) or
for the alleged exemption Any v damn
subjects the eppllmnl 10 a av ark of
with wages as . • Ie compensabon will
or offend for a. Sec 7044 Business and
Law does • apply to en owner of a propry
$ - 0n himself or through his or her own
- not Intended or altered nor sale If
within one yew Of completion the owner
or she did not build or Improve for the
contracting with licensed contractors to
and Professions Code The Contractors
who builds OI Improves thereon and
license pursuant to the Contractors
reason
/
Date Owner
tc W
Q
kW
rrwl
CONSTRUCTION L
I hereby affirm under penalty of perju 1 me
the performance of the work for cola permit
Lenders Name
G AGENCY
n Is a construction lending agency for
Is issued (Sec 3097 Cry C)
Lenders Ad
UILDING PERMIT
City of El Segundo
RTMENT OF BUILDING SAFETY
PLAN CHECK NO l ;®h J L fl -DRAWING NO
BUILDING ADDRESS TIoc96O r '!" /M� VW
TRACT
BLOCK/PAGE LOT ARC
co
G
TYPE OF CONST
GROUP Z
USE ZONE
REO'D YARDS
NO STORIES
SIZE OF CONST
USE OF BUILDING 7»c7 of
SPRINKLERED
WET STANDPIPES
41, ere SF
UBC EDa
NO
NO
IPTION OR REMARKS
NEW
ADDITION
ALTERATION
A/Cr t.Sfvo bus -
cc/Gia AceO,Fy e c7- c—as
Acey71 C ySTE&iL
wit
b
I wiry mat I have read coo appllnem and stab that the Wove Imblrrlaboll is mired. I
agree to comply with all aty and mlmty ordinances and Mate laws relating to building
9ume050 rapreeenh5vat 01 that dry be enter upon the wove
P
conatruceon
mentioned
Signarur
AP 14nt
APPL REC
BLDG SA
h
J
SD
0
FOR DEPT. USE ONLY
.%1rMi✓e
FIRE DEPT
PLANNING
PARKSIREC
PUBLIC WORKS
N
CMP USE
CMP USE
BLDG AREA
CMP USE
BLDG AREA
BLDG AREA
VALUATION OF JOB $
W
W
S M I FEE CAT
ENERGY PLAN CHECK
69, Poe , BO
$
PLAN CHECK FEE
BUILDING PERMIT FEE
PLAN RETENTION FEE
T
Is
T$/g._ 0 i 1 r 5
PERMIT ISSUE DATE
REA
CONDITIONS BELOW ••..
The work authorized try Issuance of mr permit is object to W ma rules and repulaborls she forth m
the ordinarce and amuamuts M the Clry of El Segundo and 01. laws 01 me State M Calffomla in
regard to such wool and all amendments the eto
Thu permit becomes null and void 0 wOm is not commenced within one hundred echly (180) Jaye
from data of Issuance of d wbk 15 suspended al ;any time anmg construction (b tge ayry pel5Od of
time or a any work is done in violation of the City Ordmence or Stab laws governing same
VALIDATION
Date
NFITE (Dept ) YELLOW (Applicant)
rbs FORM B 102 Rev Irg5
INSPEt' ION RECORD
,
Plan Check No.
APPROVALS
DATE
v.
INSPECTOR
APPROVALS
DATE
INSPECTOR
EXCAVATION
'
DRYWALL
FLOOR JOISTS -
STEEL
FRAMING
-
WALL
ROOF
BOND BEAM
INSULATION
PANELS
LATH, EXTERIOR
RETAINING WALL
LATH, INTERIOR
MASONRY
ACOUSTICAL
FENCE
ENERGY
_ _. __ _ _ __
FINAL -
l
101
_
REMARKS
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