1233-02 - 901 NASH ST N= Gt90 16ss
C
No. 1ss-)
VERSION 12-2000
OWNER -BUILDER
I hereby affirm under penalty of penury
License Law 1« the maoanlg reason (Sec
My city or county itch requires a pernut
repair any NUCYQe onor to its issuance
to Ede named statement that he or she
Contractors License Law (Chapter 9 (commencing
Busmen and Professions Code) or that
for the alleged exephe My wdabe
die aepi®nl to a evil pe atly
1 as owner of Om properly or my
pensation v.0 do the wank and the sbuaure
7044 Buenas and Pmfesssans Code
apply to en sew a properly who build
work himself or hence « h S
Improvements we not mlerd l( 0
movement ad wui sold one r
burdenOf praelp mat he or she didral
ai as °met of the y a
to crostrua be (Sec 7014
contractors License nOt ape
proves thereon and contracts for Such
pursuant to the edam ldense Law
I am 1 under Section
DECLARATION
that I am exempt from the Contractors
7031-5, 8ueote s and Professions ..
to construct after Improve . - a- or
eh, requires the applicant tor,:. Pena
h licensed pursuant to the .. !ions of the
with Sac' 7000 Dn 3 of the
he or she is exempt ! - . and to bass
of Sec 7031 5 by ,. apptl®d i« a pemit
of net mere Nan . . hundred deters ($500)1
employees wages as Mar sole com-
IS • ended Or altered for sale (Sec
The . License Law does not
«ice.. _ thereon and wale does such
her employees provided that such
f 11 however to bold ap or fro -
the weer -Nam« Ma have to
or sn«we for to purpOSe a sale )
xW Lively contracting wN pconsed can-
Business and Professions Code The
to an Owner ol property who pods or im-
prgeds • ith a erltradtl(e) k ens.
)
B 8P C for this
reason
Date Signature o(Game
LICENSED CONTRACTORS
I hereby affirm under penalty of penury
Chapter 9 (commencing with Secdn 7000)
Prot lode and my !tense ism him
C ct4D s eq-si8
DECLARATION
Nat I licensed
am under mansions of
a DMsan 3 el the Business and
1«Ce and erect
j.1 l��.Ly]�
Moen Class
4-2/4A 02-
License N hen ate
E+mva
Date
Signature of Contractor
WO
I I ! h eaffirm under penal
0p !have and will median
compel a tfor y I«
I the work for intkh
yeandwillmaintainLade
Id a
'C MPENSATION DECLARATION
a one a the iota sg ana\ P�
een 3 70 0f the a orCodeself-Insure work \•`JY,"/,
by Segos the Labor Code 1«�
tad,ermd Is issued
as
rs'tie ornanCe 01 the
Mr
t s the p surancecc of tha p tor ratan pa it _
Ms«arao carder and neap nember�
K-11.410 - - - -
the Leptsn (,octe
A issued My worked compensation
Cat Sl1Ti4TiL
PoOwNo e./T6— -
(nnrwi Mb mewed a le oncemomrhatt mum dice);wuf
I 2I certify tal In the performance of the work for Mach Las penal is Issued
not employ any person In any manner so as to become subject to the workers'
cempensatron laws of CaManua and agree tat if 1 Should become subfed to the
workers compensation prow-. • Sec 3700 of the Labor Code I shall f0rthvath
comely MP thee provisions
tIn .I.. if., ,
t
Signature . -Mormon
WARNING FAA CURE WORKERS COMPENSATION
COVERAGE ISUNLA - , • SHALL SUBJECT AN EMPLOYER TO
CRO WAL PENAL • CIVIL FINES UP RICHE HUNDRED
THOUSAND DOLLAR: , CO ate), W ADOHION IC THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR W SECTION Me OF
TIE LABOR CODE. WTEREST.. AND ATTORNEYS FEES
CONSTRUCTION
I hereby affirm under penalty
for the pedenance of the xorF
Lenders Name 17
LENDING AGENCY -
of penury that twe is a rAnsmwtlan lending agency
tor which ths pet is issued (Sec 3007 Cry I
hin
"�/ L._
Lenders Address
I certty that I have read this
oared 1 agree 1000nlply with
Iaong m Duiaad construction and
to east upon the abovom
1-2.141 V fl so
application and state that the above mf«maton h
et city and minty «dbance9 and slate laws re-
hweby authorize representatives «INS oty _ —
ed property for nspesbn purposes
6.1•44✓
ate
SwW Meant or Merl
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo, CA 90245
SITE ADDRESS
9 m i N • RA slt sT1gar
SURE 'IDENTIFYING NUMBER r7
S OM , t cc
ASSES RPMCEINUMBER
ask ttSl rum 10OS PARCEL 033
APPLICANT PERSON
1/41 012-64, Iglu A o, wt s
DATE
9.tJt 01?
ADDRESS
C lig L CRA Vcr b 12-F
PHONE NO,reld)
t06 a3' s
CRY
CO hAFA .P-
STATE
CA
ZIP
°( 001-0
PROPERTY OWNER QQ�� �N'�/
rO IV4" Sure JC L
PHONE NO
—.
ADDRESS ICI � H.Choi • ` I NA sBTPTE
s U. 400
Cei
ZIP
Q o7415
TECT-
PHONE NO
ADDRESS
IA
C�
'ENGINEER
STATE
ZIP
PHONE
ADDRESSSS
ADDRESS
I T II• / I
CITYca
STATE
ZIP
O
EPa (. EP1Gaw GO M..
C1IVIIC NO
1_SO-
ADORE S
Geliat Ciliktker b%a-
PHONE NO csen'
Fo6-332p5
CITY
COW/16420.w
STATE
CA
ZIP
,co`to
PLAN CHECK/PERMIT NUMBER /5 to-
C.MPUSE
-LW AREA
NEW
RESIDENTIAL
CMP USE
BLDG AREA
ADDITION
COUIIIERCIAL
JC
LAW USA
'BAIL. AREA
AL TI N
DESCRIPTION 0
r-we911sf{
WORK
I T./115-Gq- — C1-) SWtQIc _
1)EEre ar n&. $ C1-) Avooraccir-dia
,*_I_4.r' IA.0a1tXa .•wtrzAM6
1.A To UP Nowt 046
Yield,—
tWl-oolc-o—t
6 rc�'DC
REF
c4 53 -02—
U
6
rYPE(S1 OF CONSTRUCTIOI
Z
SQUARE FOOTAGE
NO OF STORIES
FIRE SPRINKLERS
LL?7 NO
STATISTICAL CLASSIFICATIOI
NO
UNIT(S)
gip
EFFECT
01Cfr.
rO �Z ��
S •-S p SVALUATION
PIAN CHECK FEE $
ENERGY PLAN CHECK $
)
I /paJL
V
'HLLEIPT NUMBER
I INHIALS
DATE
5
PLAN CHECK FEE 5
ENERGY PLAN CHECK $
REVISED VALUATION
RECEIPT NUMBER
INITIALS
I GATE
PERMIT FEE $
RETENTION FEE $
SMIP FEE S
ACCELERATED FEE $
TOTAL BUILDING PERMfT FEE $
v/f�—/( /n�1��
/ '+"/eA/`/�l—
/�/✓D
/s )�✓
12
sly{(
/8 LL/L
V
FEES PAID
DIST PAID
WORKS FEES PD
PERMIT OBTAINED I-1
APPROVAL
APPROVAL
APPROVAL
WASTE APPROVAL
_ SCHOOL
_ HEALTH DEPT
SANITATION
FIRE DEPT
1-1 PUBLIC
r1 SCAOMD
I —I OSHA
INDUSTRIAL
INITLALS
X�
DA7��RECCEEIPTTNNUUMBER
EIN 5 �i /,
DATE
z/4-/og
NO
INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
81
Location and setbacks
82
Solt Engineers Approval
B3
FoundabonTronch forms
B4
Swcbral concrete stab on grade
65
Rased floor tremolo
B8
Under flow nyaabon
BT
Fro level floor sheahng
Be
Second levet floor sheathing
B9
Turd level floor sheaving
1310
Roof sheathing
811
Concrete block
lot GroutM
2nd Gan M
Iro Gout WI
son Grout Ill
1312
Steed framing
B13
Fre Dete frame nspecbon
B 1 s
B W dap Dept frame nspedm
B16
Fre spmller hangers
B16
Insulatonleather stryping
B17
mtenor lthandar drysol
B113
Exterior DM
819
Rated IborlCusng assembles
B20
Rated wall assemblies
821
Rated openng protection
B22
Rated shaft consluoon
823
T-bar cadvga
B24
Loldranage
625
Plannng Dept Approval
625
Fre Dept Approval
1327
Public Works Dept Approval
028
Fetal Building inspection 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 Me Building Official, the owner's agent may sign for permits other Man the initial or shag building permit
We the applicant or future bolding occupant handle a hazardous malenal or mixture contaarlg a hazardous material equal to or greater gal he amount
specified on the hazard0us materials IMMNMn guide? Yes or NO now)
lithe answer to me question was yes we the proposed butting or modified tadey be vamp 1000 feet of the outer boundary of a school?
Yes or No tonal
I have read me hazardous malenal information guide and the SCAOLO pbm ng chedls' I understand my requirement under the Stale of Catfoma
Heath and Safety Code Section 25505 25533 and 251334 conceding Kazamous malerels reporting Yes or No tool
NAME SIGNATURE
INSPECTION NOTES.