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1221-02 - 2030 MAPLE AVE E02/09, - a2ao VERSION 12-E000 OWNER -BUILDER DECLARATION I hereby affirm under penally of p anury that I am exempt from the Contractors License Law la Me idpMng reason (Sec 7031 5. Business and Professions My oty or county Much requires a permit to Construct, Stec improve, demolish. repair any structure prior to its Issuance, also reamers the rani for such to Fee a signed stdemenl Mat he or she Ls licensed pursuant to the provisions Co/tradas License Law (Chapter 9 (comen' g WM Sec 7000)of Div Business and Professions Code) or Mal he or She Is exempt therefrom and for the alleged exernpbon My violation of Sec 7031 5 by any appfrant eu�athedyf ends applicant to a penalty of not more than five hundred dollars Lode or perm of the ' 3of the ' . an pasts for a permit ($500) ) sole com- sale (Sec not such such or an - the of Sale I con- The O im- u I, as weer of the property, or my employees mma wages as Mgr pensation wi do the work, and the structure d rw Intended or offered for 7044. Business end Professions Code The Caroadas License Law does apply to an owner of property Mg pips or Improves thereon, and win does work himself or herself or through las or her over employees, provided that improvements are not intended or offered for sale If. however, the burg prevenient U sold within one year of completion the wnwr-0tvper ova have burden d prorag that he or She dal not bap Cr improve to the aaoOSe I, as view of the properly. am exclusively coniremng win licensed traas to constrict the project (Sec 7044 Business and Professons Code Cantredors License Law does not apply to an owner of property who SuddS proves thereon, and who contracts for such protects both a mnpadorg) license pursuant to the Contractors Ucense Law ) 1.1 I am exempt under Section B AP C for the reason Date Signature of Owner LICENSED CONTRACTORS DECLARATION I hereby of and ' affirm under penalty of perjury that I am lcensed under provisions Chapter 9 (anmerrag Mm Section 7000) of Division 3 of the Business Prcow.essms Gp, and my license a in, torce end erred i 1 al, Class , in i�/. 4 m Exonran Date D . alder of Contractor WORKERS' COMPENSATION DECLARATION I hereby affirm under penally of perjury one of the following dedaration by permit are I have and will maintain a certificate of consent to self -insure for cdmpensabon, as provided for by Section 3700 of the Labor Code la i of the work to ytdm this penal or Issued nave end ova mamtan workers' compensation nmarance as moored of the Labor Cade, la the performance of the work to Nam els Is issued My workers' ompepennssaatm- Insurance tamer end policy number Game / atmo"w�wui- - sp. �r�� ( pros No Rl (G/ an inn wand needmtbdnpwdeb+ pawn kr d//,wdrvpcuwrdlaol>tml 6 ri I certify that In the performance of the yak for Mach ass permit is I not employ any person in any marries so as to become subted to Isis Cepada, issued, Me workers' to the ford -froth b compensation of and agree that if I should become Subted compcomity Pathensation workers'gj enssation wog of Sec 37 I Kaber Code I Shall provprovisionssla lo ire f Wmamea Aori ant - WARNING FAILURE TOSECURE I4ORtERS'COIWENSARON COVERAGE IS UNLAWFUL, AND SMALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP MOMHUNDRED THOUSAND DOLLARS (Sloo,0Jw, IN ADDITION TO DIE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR N SEC DON 3700 OF — TNE LABOR CODE NTERES r, AND ATTORNEY' SFEES. - CONSTRUCTION LENDING AGENCY - - I hereby affirm under pram of penury that there is a cdneauction lending agency for me performance of the WE for them W s Is issued (Sec 3097, Co C I Len de(5 Name -- - - _ Lenders Address I candy Olaf I have read the and stale that the above Information IS coned I agree 10 comply with .,. and county nee - state laws ra- latirea to wong omstudion, and j• ,4 , , :sin, of Om ate. to enter the abOV.Inen yy', / Aliwl`iS Me mature • ADOIKa t or Mend BUILDING PERMIT BUILDING SAFETY DIVISION, COMMUNITY. ECONOMIC S DEVELOPMENT SERVICES DEPARTMENT 350 Main Street El Segundo, CA O0245 , SITE ADDRESS - E. 1,o3o MAPLE sr' SUITE / IDENTIFYING NUMBER 'AYTHE con. 15LD6 W— 23 ASSESSOR PARCEL NUMBER Boot PAGE PARCEL APPLICANT /COMACT PERSON Le He Meta NA � n44nroad oveArs/Ex "DAFE if ,,, ADDRESS 'nay $ANTI Monies ad, PHONE NO 310 yy/-j3/o CITY Lma MI4Eta5; : STATE - 64 ZIP - joo zs PROPERTYOWNER , f�A)1 rhea o k PHONE NO ADDRESS ,Aoom EL Sac Gvavra /3Ls- CITY EL seacenro STATE CA ZIP 9 0oay5- ARCHITECT _ PHONE NO ADDRESS CITY STATE ZIP ENGINEER 4, H. HA 7'AVq c 4i An HOLGewna uE K PHONENO yy _73/c ADDRESS a{// if/Esracror 5rR grJlFLR CITY Loa 4MGEc es STATE c° 4 ZIP 9ao/3 COMRACTORS NAME P CRY LIC NO fl '2 - ADDREPOW SS l rnW,lS (ERA JJ ✓✓ 0 CITY i/aiiknkic STATE C1 ZIP 9/ate PLAN CHECK/PERMIT NUMBER: i z � _ 2- b 'UP USE• W RHEA NEW NrsIDEN GAL LTIP-RSE .; tut, AHFA ADDITION COMMEf♦ to x Um, Ube BLW AREA AEA / DESCRIPTION 0?WORK Ay` 6ggap,A,a 4 PRveavG eQ(b a-G,/ltf2 REF d Illy -oz OCC GROUP(S) tYPE(S) OF CONSTRUCFIOf SQUARE FOOTAGE NO OF STORIES FIRE SPRINKLERS YES NO STATTIISTIGAI, SIFICATIOt ((coo UNIT(S) CODEJN EFFECT EC y 35 PLAN CHECK FEE $(/�� s"3.7y VALUATION ENERGY PLAN CHECK $ // RECEIPT NUMBER INIGALS Ablerk/-21 DAiE -0 2 $ PLAN CHECK FEE S REVISED VALUATION ENERGY PLAN CHECK $ RECEIPT NUMBER INDIALS DATE PERMIT JJ FEE S ��7S/. ob RETEN ION FEE $ S-.50 _ SNIP FEE $ ACCELERATED FEE $ / TOTAL BUILDING PERMIT FEE S /a/CO . Si / _ SCHOOL FEES PAID _ HEALTH DEPT APPROVAL I —I SANITATION DIST PAID =M FIRE DEPT APPROVAL I-1 PUBLIC WORKS FEES PD I —I SCAOMD APPROVAL Ii OSHA PERMIT OBTAINED j—j' INDUSTRIAL WASTE APPROVAL i to RECEI TTTI N INITIALS DATE /L/ �IR'/�/•� •FIN S � /y//� D��I��I W- c- r -13 v_ Z m z -13 r_ C) 0 rw NO INSPECTION DATE INSPECTOR REQUIRED BUILDING INSPECTIONS AND APPROVALS Bt Location and setbacks 82 Sob Engines Approval 03 FaundabaMrendl loom 61 Streclerat concrete slab on grade 05 Ramad dos framing BI3 Under door nssbon BT Fesl level door sheathing Be Second level floor sheathed 89 Ttrd level Rea sheathing B10 Roof sheathing B11 Comes block tat GroutM 2nd Seoul IA 3rd Grout bit sth Grout lit 1312 Steel tang B13 Foy Dept frame nspecbon B I4 Buidng 0ept frame Inspection B15 Fire spnMrlafgrs B16 thsutabo.teather sewing B17 Intern bet and/or dywel B15 Ealenor aei B19 Rated doprlCeving asSbntbet B20 Raled wal assembbea B21 Rated opening prdecbon B22 Rated shad cprrauceon 823 T-bar casings 824 Lot drainage 825 Plannng Dept Approval 026 Fee Dept Approval 827 Public Works Dept Approval 625 Foal Buidag nspecbon 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 Brisling Wag the owner's agent may sign for permits after than the Initial or shell bv89ng permit Wei 01e applcanl or future building occupant handle a hazardous malanal or mhlure contested a hazardous malarial equal to or greater Nan the amount sneaked on the hazardous materNb Mvmaom gedei Yes or No oval lI the answer to the question was yes. wu the yopmed buibtg or rnodfied achy be within 1000 leer of the outer boundary of a school? Yea Of No rm+t I have read the hazardous material elonnanon guide and me SCAOMO permitting chec*lsl I understand my requirement undr the State of Ca to na Health and Safety Code Section 25505, 25533 and 25634 concerting hazardous materials reported Yes of No Imacwi NA/AS SIGNATURE INSPECTION NOTES: Ra. xmab