1113-02 - 2031 MARIPOSA AVE E (3)VERSION;imaa
OWNER-BURDER DECLARATION
u/Mw penalty of
Why _ that I am exempt horn the Contractors
Law b the taexng reason (Secec 7031 5. Business and Professions Cale
My city or county Midi requires a permit to construct, altar. Impose. demolish, or
reps any animas, aria tom issuance. also requires the agora^ to axle permit
to Se a signed statement that he or to Is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Sec 7000) of Dn Oct the '
Business and Professions Code) or that he or the M exempt thGatrom and the basis
for the aaeged exemption My violation of Sec. 7031 5 by any applicant for a permit
s e the spoken! to a ass petty of not more than five kindled dollars (5500) )
I,
as owner of the property, or my employees with wages a3 tier sole di.
peraaba4 MI do the work, end the etumoe is not intended or ared for sale (Sec
7044. Business, end Professions Code The Contractors se rawdoes not
appry to an wma d prtpey wfo or Improves . and who does such
work rinsed Or herself or trough Ns won provided that such
improvements we not Intended or for If. however, the Sodding or im-
provement is sold within one war . the aagrawder won have the
burden
of proving that he or sere ma or RCMP* for me artpose a tale )
I, as mwier of the property, a sN contracting with hcensed con -
to CadaesLicensethepro)ect iBup�aid ProfessionsCodeThe
contractors License Law spay .-y]lI of as rof a sro anode hf
prates thereon and who tracts for prof with a antraihl(s) karma
pursuant to the License Law )
Q lames err Section BSPC for this reason
Date Signature of Owner
LICENSED CONTRACTORS DECLARATION
-
!hereby efem under penalty of perpny that I am icensod under prmvtms of
Chapter 9 (commencing Mtn Section 7000) of DMslon 3 of the Business and
Profession and my license Is In lull force and fled - -
75F z 2 3 / ii-o
Date
Date Signature of Contractor
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penally of perfuy one of the Idiwwng dedarabms
Maya and wt1 maintain a col tale of consent to self -Insure for rakers' -
compensahon. as provided for by Section 3/00 of the Labor Code, for the per-
formance work la mach to permit W Issued •
ad wet CodeQt wales' compensation eorth insurance. t rewired by
d w rmor(:ode rot the pen arse aTarodicto wrath We Damn
Derma
Is Issued My workers' Iarce adpol number are
Carder or a
xe . - -
Cara No
Iila seam nisi is se wiped Ire men a toy ma M1w•a mare Wooer w lot
I certify that In the performance of the nark for which this permit is Issued
I ss�� not employ any person m any many so as to become subject to the workers'
oorrymaaan laws of California, and agree tut if I should become sabred to the
went' canparea&on provisions of Sec 3700 of the Labor Code, I shall IoMm
�snplv with Dices onTlaimb
Date SMatre o Appaa ..
WARNER) FAILURE TO SECURE WORKERS' COaPEIISA ION
COVERAGE C UIMIAIrTUL, AND SMALL SUBJECT AN EMPLOYER TO
CRIMINAL PENALTIES AND Chia FINES UP TO ONE HUMORED
THOUSAND DOLLARS Nr00.000A N AoomoN to ME COST OF
COIPBISA TRW, DAMAGES AS PROVIDED FOR N SECTION S708 OF
THE LABOR DGDF WTEREST AND AT rrwtn:f FEES
CONSTRUCTION LENDING AGENCY
1 hereby affirm Oder penalty d penury that there Is a constriction lendig agency
for the performance or the work for which this permit Is issued (Sec 3097. Ch, C I
Lender's Name
_. _ _ _
Lender's Address _ __ _ -
I certify that I have read ties sodiatm and tale that the above Tfatnation Is
pared Iagree lo dryad and state taws re -
Mann d her authorize dm oh
Men the n ed
00)-
Dale of Mdrcant or Mont
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY. ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
- 350 Main Street
El Segundo, CA 90245
SITE ADDRESS
031
C Vet
fa -
SUITE / IDENTIFYING NUMBER
ASSESSOR PARCEL NUMBER
stun PAGE PARCEL
A 1ANT/CONA RSON,
Ai �66-/
DATE
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RESS
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PHON -,
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ere nPHONENOKi-/lAe,r)
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ADDRESS
7,220 °DelftrWnh ,li
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STATE
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PHON6
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CITY
STATE
ZIP
ENGINEER
PHONE NO
ADDRESS
CITY
STATE
ZIP
•+ ' • OR'S NAME
al,rcy.Sur ,,2
CITY LIC NO
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ADDRESS - - a/Jf/¢
PHONE NO r6 n`
CITY
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PLAN CHECK/PERMIT NUMBER: lit 3- Z
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CAP USE
BLDG AREA
NEW
RE IOEMIAL
I,MP USE . i
BLDG AREA(
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TYPE(S)
FIRENKLERS�U�
OF NS
SQUARE
[/�p�71p�`Tp$'/AGE
NO •F STORIES
STATISTICAL CIASSIFICATIOI
eo/ry�y/�
UNIT(S)
C•• EFFECT
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PLAN CHECK FEE (/ /
/
ENERGY PLAN CHECK B//
7 7
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VALUATION
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4-A 33
/tECEIPT NUMBER
-
INIl 'ALE
DATE
(
o-31 D 2-
5
LAN CHECK FEE $
ENERGY PLAN CHECK 5
F
REVISED VALUATION
RECEIPT NUMBER
I INITIALS
DATE
PERMIT FEE S
1) /i RETENTION FEE S
SMIP FEE Ct'%5
ACCELERATED FEE S
TOTAL BUILDING PERMIT FEE 5
�q•�
O /y} .5�js t el l
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i 9. 95 .
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FEES PAID 'I
DIST PAID
WORKS FEES PO
PERMIT OBTAINED
APPROVAL
APPROVAL
APPROVAL
WASTE APPROVAL.
_- SCHOOL
I HEALTH DEPT
. SANITATION
IMIM FIRE DEPT
rn PUBLIC
I—1 SCAOMO
I —I OSHA
r—I INDUSTRIAL
RECEIPT NUMBER
DAT 1?
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INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
BI
Location and setbacks
112
saes Engineer% Approval
B3
FoundaboruTre dt forms '
B4
Structural concrete slab on grade
115
Rarsed floor framng
88
Under floor isolation
BT
Fast level rem slaathng
08
Second level floor sheathing
Bg
Bird level floor sheathing
BIB
Roof sheathing
all
Concrete block
1st Grout NI
2nd Gout MI I
3rd Grout In
aN Grout lm
, •
I
812
Sled framing
813
Fre Dept frame nspecbon
Bf a
13uddrwg Dept frame napecmrw
//' Ifl -O Z
C♦l - //yytt..//�� ��
7T r�/' `-+
815
Pre sprmkler hangers
/T r
816
Insulation/weather stripping
817
Interior lath andor drywall
BIB
Eaenorlam
819
Rated Ibor/Cedng assemblies
E120
Rated well assemblies
821
Rated opening protection
B23
Rated shaft certsbdmon
u
B2
radmgs
/WQ-kw.
/1):CrEtif
824
Lot
d banapa
825
Planing Dept Approval
026
Fee Dept Approval
827
Public Works Dept Approval
B28
Final Bulking Inspection approval
'
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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 Budding OfNe at OM owner's agent may sign for gamins other than the initial or shell building permit
We the applicant or future bolding occupant handle a hazardous matenal or mixture containing a hazardous material egual to or greater than Me amount
apeted on the hazardous matenals Nlonnabon guide? Yes or No (won
If the answer to the question wes yes, ve the proposed baking or modified Malty be within 1D00 feet of the outer boundary of a schools
Yes or No (rat
I have read the hazardous maternal nfauaben grade and the SCAOMO pemlmng cheddet I understand my requirement under the State of Cdibma
Health and Safety Code Section 25505 25533 and 26634 concerning hazardous matenals reporting Yes ' or No cool
SIGNATURE
INSPECTION NOTES:
W. In10>