1134-02 - 1550 MARIPOSA AVE EVERSION 12d000
OWNER.UILDER DECLARATION
I hereby affirm under penally of perjury ihal I am exempt from the Caeadors
License Law tor re Meowing reason (Sec roil 5, Business and Professions Lode
My ay or county vetch requires a pennil to construct, alter, mprove, demoksh, or
repair and slucture price to as issuance, e, also rebuses the apdcant Id such permed
to Re a signed statement that he or she Is licensed pursuant to lie provisions of the
Contredas License Law (Chapter 9 (odmnenong with Sec 7000) of Dry 3 of the
Busmen and Professions Weal or eat he or she is cannot therefrom and the bans
for the aleged nempoon My violation of Sec 7031 5 by any applicant for a permit
9e aypocard to a ON penalty of not more than live hundred doSars ($500) )
I. as w,ner of the property. a my employees with wages as thew sole coo
pensabm, nor do the wok. and the stuciure is not Mended a offered for sale (Sec
7011 Business and Professions Code The Contradaa bone Law does no
apply to en over of properly who builds or Improves thereon end who does such
work lmnsof or herself or through Ns or her own employees provided Mal such
Improvements we not intended or offered for sale II, however the buildup or Im-
proWment is cold wvthn one year of Completion the owner -builder vet have the
pomp that he a she did not bold or improve for the purpose d sale I
AlI as ewer of the property, an exclusively contracting with licensed can-
to croseud the project (Sec 7044 Business and Professions Code The
Contractors License Law does not to
apply an owner of properly who builds or Im-
proves thereon. and who contracts (or such aaeds with a contractor(s) Sc nse
pursuant to the Contractors License Law )
I• I an exempt under Section B SP C for this reason
3 I-0 3 pA a Q n^ ^ .1.
I y'•^'W 'U y�
Dab Slnalure al Owner
LICENSED CONTRACTORS DECLARATION
I hereby affirm under
penalty of perjury tha am Mensed under prorsions of
Chapter 9 (commencing with Section 7 Division 3 of me Business and
Professions Code and my license is n , force and ettect
License Class License Number Expraton Date
Date Serrature of Comrades
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the loparng declarations
I] I have and W a maintain a cal Trrate of consent to self -insure fix workers'
canpensahon es provided for by Section 3700 of Ire Labor Code for the per
Ibnnance of the work for Mach this permit is Issued
sackI rove and war manacn waters compensation Insurance as realred by
lW d the Labor Coda Ia me pMamance or the won to, wysdi his pent
Is issued My workers compensation Insurance canter and policy number are
Carnes
Poesy No
Ms won roe ^p browned 4 ow Cea ebwr t.d ours dlhtlnwl
1 EaI only that in the performance of the work for Mich tali permit Is issued
not employ any person in any manner an as to become subtext to the workers'
amp isabon lam of Caslanta, agree Mal it I should become sut1ed to the
workers compensation 3700 of the Labor Code, I snag Whom
Mowry wai those prow
1-3(-0 3 (ta/xm.e cite d— ._
Date Signature 0 Appkfant
WARNING FAILURE IO MORuEAS'CGM'ENSA TON
COVERAGE IS MANFUL. AND AND BE
SHALL SUBJECT AN EMPLOYER TO
CROMVAI PENALI AND OWLNNES uP TD ONE HUNDRED
THOUSAND DOLLARSS f1100.00a INADDITION TO THE COSI OF
GOWENLNON, DAMAGES AS PROVIDED FOR IN SECTION S)M OF
rn LABOR COOS, INTEREST. AND ATTORNEYS FEES
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of penury that mere is a construction lending agency
To the performance of the work for Which this permit is Issued (Sec 3097 Cm C )
Lenders Name
Lenders Address
I certify that I have read thus application and state that the above Information is
anew I agree to awn* with an and county ordinances end state laws re.
ahro b bvldre MSWden soy aumaae rein awes or this city
kb er upon the above -menu for inspecten
eAThm
Data wabra led a AoeAI "
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY. ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo, CA 90245
SITE ADDRESS
I?50 E MA-RiPOSA
SUITE / IDENTIFYING NUMBER
ASSESSOR PARCEL NUMBER
ease PAGE PAPAL
APPLICANT/CONTACT PERSON
MAIQUE-1._ LAM
'DATE
II- -Ca
ADDRESS
I�i131 LAf C4 A-V6
PHONE NO
6944_n
CITY
L AV RN t �
STATE
aptAnte°
ZIP
PROPERTY OWNLR IPHONE
Fpniv_�eQO�
NO
���AciD
ADDRESS
l Pa e. MAfRI R)Sa
CIIITTTYYI'� 4tEMEJW
STATE
s
ZZII
EE1�2-L5
ARCHITEC
SAµS AV Cat
PHONE
ADDRESS
CITY
STATE
ZIP
ENGINEER
PHONE NO
ADDRESS
CITY
STATE
ZIP
�R'S NAME / 'are
nutIA � Id /A-
LIC NO
ADDRESS
PHONE NO
CITY
STATE
ZIP
OR/I- ltp
I
PLAN CHECK/PERMIT NUMBER:/13(/, tr
LMP USt AREA
NSW 1
REVNTIAL
tMP USE JBLCO
BLUG AREA
ADDITIOeT�//�'
COMMERCIAL
LMP USE
SLUG ARE
AL TERAIION
DRl9jl(JNQ�C
MTMGA
MP/TER
teb12-a
2UGM
(.FAME- 1
REF a -
OCl
PtSt
I1 ONSTRUCTiOt1/1
MI
SQLNeJt$EfjfO.AGE5
(T ��CCALI
NO OF
STORIESFIRE
SPRINKLERS
Y S NO
AT1�
STATISTICAL L�AjSSIE IC TIOI
LASSIE
Liu
�
UNITQI
1
C
E • �'
ll��)
$ $L �Ir
NAN CHECK FF1
$
ei
Q b
'RATION / I
ENERGY
PLAN CHECK
$ /
mil^
J'
ktCtl ITj.I.2 qo'
•
li so,
Emir c 2-
$
Pt AN CHECK EE
S _
REVISED VALUAT ION
ENERGY
PLAN CHECK
$
RECEIPT NUMBER
INITIALS
DATE
//7��1 %
PERMIT FEE S SZ91/ T)
//] x�}
V /(J RETENTION FEE /5 ,6,."0�a�
SMIP FEE Ay.40
may
ACCELE RAI EDFEF $ �a-�/LE
/yy��
_ TOTAL BUILDING PERMIT FEE $ /0_ \/' N
MESCHOOL FEES PAID I 1 HEALTH DEPT APPROVAL
1111.1. SANITATION DISI PAID FIRE DEPT APPROVAL
1—.1 PUBLIC WORKS FEES PO r1 SCAOMD APPROVAL
1--1 OSHAPERMITOBTAINED 1 INDUSTRIAL WASTE APPROj AL
�J C
�l/ 1
I1
■INITIAL$
X/Jj air'
OAIE//-Q/ / � -wwOL\
11NALED BY // �/�.P��
4 r16% r`
pjeT[ q�J, �J
u'/V
NO; B15VECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
DI
Location an06amadlI
B2
Sob EngYMML 4proral
&T ,
Fata3atayTren farm
�j L
abate)
Ba
Sf°cwM Canaille Slab On End •
11
1
EIS
Rased Boahaninq
.�1^.�L
�t /.. 1 i 0 3
BS
Under Snot a1M60on
)
B7;
-Fry level Soo sheatalp (
l
BB
Second level floor sheattmg
l
BS
That level Door Meting
BID
Roof sheaths_
111l•
Y
CancIa Flak
IU GIDA WI
.
2nd Grout r'
Pod Grout El
B12
Sleet Jarring
1313
Fee Dept fame anpecuon
B14
Building Dept Slone Inspecom
815
Fre spmgter hangers
BIB
MualonMeedw salppls
B17
olerw at anderd,Wlafl
B16
EMsbam
Big
Rated BoorCeang assembles
020
Rated *al assembles
B21
Rated °gems protection
B22
Rated sled mmmrcton
B23
TUarstings
824
La oanage
625
Panting Dept Approval
B28
Pee Des Approval
827
Pltblc Wats Dent Approval
1326
Pal BuWtg
nspodtm approval
NAME
DESCRIBE COMPLETELY TEE INTENDED USE OF ALL SPACE APPLICABLE TO THIS BUILDING PERMIT
The following statement must be signed by the Building owner. -
(Rmen approved by the Maine OIIkY( the owners agent may sign for Permits oli w than the mdbl w shell braiding permit
Will she applicant or future WMaq ocaipanl handle a hazardous natgpl or nulure containing a hazardous material equal to of greater than the amount
specified on the hazardous matenab nfamaton guoe? Yes or No twun
N the answer tome Ruesson was yes, we me proposed building or nodded facety be within 1000 feet of the outer boundary of a schoor
Yes or No feat
•
I have read the hazardous morsel Mfor aam girds and me SCAOMD pennons diedRsi I understand my reWaemenl under the State of Catfoma
Health and Safety Code Section 25505, 25533, and 2563a concerning hazardous materials reporting Yes or No teat
I{`.I
SIGNATURE
' INSPECTION NOTES:
'1
w. rnlec