1106-00 - 2300 IMPERIAL HWY E (3)•
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NAME PEoFiCal 11 CRPIT>4-1 -
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INAME oaaA.) A- QDeiRy 1 MWiA s,
ADDRESS IIµ( �II.Ir�ig, ifi,iEPHONEflj q4.3.
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CITY LDS AtiAgiuwA L.- STATEmpaor ,
NAME TC linnf'S&YIAC&i10Y1 C t •
MAILING_ ADDRESS l Iq I,� Sr
und'"� I1 � o E Eo40-Da�,p
II
cmEl
STATE (A_
0
BUILDING PERMIT
Building Safety Division
Community, Economic,& Development Services Dept
350 Main St , El Segundo, CA 90245
24-HR Inspection Request Line (310) 322-7069
DRAWING NO
PLAN CHECK NO / 067
BUILDING ADDRESS Z VI M7tJDA(, WA/WA4
BLOCKAGE LOT/PARCEL
TRACT
k.
TYPE OF CONST
USE ZONE
GROUP
REO'D YARDS I✓
v
NO STORIES
SIZE OF CONST
USE OF BUILDING O}.Y,
UBC ED Q}
SPRINKLERED
NO
WET STANDPIPES
DESCRIPTION OR REMARKS
NO
ADDITION
ALTERATION
I hereby a0im under penally of penury Net i at 9bensee tinter provisions of Chapter 9L
(cprmrlm_Jrlg ate Satan 7030) 01 Dalian 3 of the Bermes and Professions Code and
myadaiwe tam hip Watt. GI
• rr
Lic
ense Clan �Lie No Sas tat 1f
Dab "1 I�IJI ) Cane did v� - 7, ,
ERS'COMPENS4flON
WORKER'S COMPENSATION DECLARATION
I tweet' enem under penally of pefplry one of the following dederatawn
I have and will maintain a r eab of consent to self insure for workers
IIDI
compende0On as provided for by Seaton 3700 of the Labor Code for the performance
et work anfor which this perms is ensued !�
I have d will maintain workers compensation insurance asrequired by Section 1/
of the Labor Code for performance of the wink for which this pryer a waned
My Wed( ton a ranee carrier end policy n
Carer Policy Number
(This section need not be completed if the permits for one hw,dr{d dot$irs (S100) or less
I certify that in the pedormenM of the work for which Its perms is issued I shall not
employ any person in any manner so as to become woman to the workers wmpenietn
Laws el California and agree set it I should become subs - to the workers compensaton
provisions ofn 3.7/r0w_� of the Labor e Code I shall I •yy' .. . ty,BF those
Prowl � I Sign
6I60
Date v` w
WARNING Fmtare to taeun workers companion coverage is unlawful and shall
tabled an employer to criminal penalties end civil fines up to one hundred thousand
dollars (S100 000) in addmn to me cost of compensation damages as provided for in
Section 3706 of the Labor Code interest and attorney a fees
-ithOur I MrCcii9loJTS ff5P— ? PLA5t
1 '! EL O',Mtn210LK5�5 L1.606
nr 1%U)TPL T FfiWeirFiri -
I catty Mall nave reed en appYa♦➢pn and stab 0W the above information a correct I
agree to comply with all city and con0 orNmroas end Mate laws relablg 1 bunting
construction end hereby auplpnia rePreaantOnes of con NNW tomb upon the agovm
mentioned properly for inspection purposes
Signature of Applicant or Agent
FOR DEPT. USE ONLY
APPL REC B -A
0
I
I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law
for the following reason (Sec 7031 5 Business and Professions Code) Any My or county
which mount a permit to wneauo Oho improve demolish or raper any structure prier
to Its Issuance alto requires the applicant for such permit a bole a stoned statement mat his
or she is bawnsed pursuant to the provolone or err Contractor License Law (Chap 9
(connancn g the Section 7000) of Division 3 of the Business end Professions Code) or
that he a she is exempt therMnm end be basis for the alleged eaemptin Any yofatn
of Section 7031 5 by any applicant Ian a permit subjects the applicant toe corn penalty of
not more Nan live hundred doles (S500)1)
() I es owner of the property or my wan wages compensation will
do No work end me at'uban Is not m or offer safe (Sec 7044 Business and
Professions Code) The Contractors not apply to an owner of e property
who builds or improves thereon and w such work hamsen or through his or her own
employees provided that such me not intended or offered for sal II
however the Wilding or n nt is n one year or completion the owner
Wilder will have the b al proving lee she did not build or improve for the
Purpose al sac)
( ) I as owner the properly am exclusively contracting with licensed contractors to
construct the project (Section 7044 Business and Protestant Code The Contractors
License Lew does not apply to an owner of properly who bursas or improves thereon and
who contract for such projects elm a contractors) license pursuant to the Contractors
License Law)
(I I am exempt under Sec_ B a PC Ior con reason
Date Owner
y
I
C
BLDG SAFETY
FIRE DEPT
IPIT-5-3o-01)
PLANNING
PARKS/REC
PUBLIC WORKS
O
CMP USE
BLDG AREA
CMP USE
BLDG AREA
CMP USE
BLDG AREA
VALUATION OF JOB S I U-ED Ion a Ob
W
W
S M IFEE CATS
ENERGY PLAN CHECK fly/
PLAN CHECK FEE
BUILDING PERMIT FEE
PLAN RETENTION FEE
$
SC .5
/S,7, CT
TO AL
PERMIT ISSUE DATE Of I (I Ind
W
co
LEA
CONSTRUCTION LENDING AGENCY
I hereby ammm under penalty of pw0ury that men is a construction lending agency for
the performance of me work for this permit is issued (Sec 3097 Cw CI
Lenders Name
READ CONDITIONS BELOW
r
The work authorized by issuance of this permit s subject Sall the nab and regulations eat lath m
the ordnance end amendments of the City of El Segundo and me taws of the Sob of Casana in
regard to such wont end all amendments Narita ('
Tura permit becomes null and void ft wink is not commenced within one hundred eighty (ISM days
from date of assuanp or it want is suspended at any ems barmy consVuebn to the sane pared of
time or d any work is done in violation of the City Ordnance or State laws governing same
Lenders Address
Oistrtuwn WHITE (Dept) YELLOW (Mplean)
dm FORM 8 t0o Rev U95
VALIDATION r p 039 cos / 0030(#& 5'
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