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113-02 - 412 OREGON STVERSION 12-2000 OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the tollovnnp reason (Sec. 7031.5. Business and Pofessions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure. poor to its issuance, also realires the applicant for sucn permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors Ucense Law (Chapter 9 (commencing with Sec. 7000) of Div. 3 of the Business and Professions Coder or that he or she IS exempt then om and the basis for the alleged exemption. Any violation of Sec. 7031.5 by an pplicanl for a permit subeds the applicant to a civil penalty of not more than by undred dollars (5500).): I, as owner of the property, or my employees wi ages as thew sole cam. pensation, will do the work, and the structure is not' ed or offered for sale (Sec. 7044, Business and Protection Code: The Co tors License Law does not apply to an owner of property who builds or i Dues thereon, and who does such work himself or herself or Through his or employees, provided that such improvements are not Intended or off for sale. If, however, the building or im- provement Is sob wMn one year of olelon, the owner -builder wall have the burden of proving that he or she not build or Improve lc( Ule purpose d sale.). Q I, as owner of the prop , am ex.isively contracting with licensed con- tractors to construct the pro (Sec. 7044, Business and Professions Code: The Contractors License Law s not apply to an owner of property who builds or tm- proves thereon, and contracts for such projects with a contractor(s) license pursuant to the dors License Law.). CI I am ex under Section B.SP,C. for This reason Date Signature of Owner LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and fie l Professions �sCCode. and my license is In full force and effect.31//��/eAL� 5 /0 Ucense Class License LrI0u onDale -o4 Date Sia Contra WORKERS' COMPENSATION DECLARATION sIherr by affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for nsation, as provided for by Section 3700 of erne Labor Code, for the fonnance of the work for which this permit Is issued. El I have and veil maintain worters' Compensation insurance, at reouir Sec. j!W 01 the Labor Code, for me performance nt the work ter which ills nut is issued. My workers' compensationio+insurance carrier andd policy number are: Carrier Sn ,C Q �C Policy No. / /(A LI —10 (1M nMm real m�rn�rcd�FF fnFo obm kw one huarod *oak (S10010r bat I —I I certify that in the performance of the work for which this permit is issued, 1 1 not empty any person in any manner so as to became subject to the workers compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Sec. 3700 Labor Code, I shall forthwith cwi th (it�h those provisions. c Date ure of p icant WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($104000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3704 OF THE LAD OR CODE. INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I hereby affirm under penally of perjury that there is a construction lending agency far the performance of the work for which this permit Is issued (Sec. 3097, Civ. C.I. Lender's Name Lender's Address 1 comfy that I have read this application and state mar the above information is correct. I agree to comply with all dry and county ordinances and state laws re- lating to buudmp construction, and nefeby au e representatives of this aty to enter upon the above -Mentioned thane r y i ection purposes. zaQ..®,2 Dale Signature of Apple or Agent BUILDING PERMIT BUILDING SAFETY DIVISION COMMUNITY, ECONOMIC & DEVELOPMENT SERVICES DEPARTMENT 350 Main Street El Segundo, CA 90245 I Rwnueat 1 inn' flint 5fd. SITE ADDRESS "Me Die6.64/v Sr UITE / IDENTIFYING NUMBER ASSESSOR PARCEL NUMBER BOOK PAGE PMCEL APP CANT/CONTACT PERSON DATE DRESS /35?? vcvrve 4 &,A1 PHONE NO. CITY P 't 1 WC STATE Qt ZIP 3 PROP R WN R c eatileMe PHONE N QN A �){'J� ?/o 722- /i� fft[DR7-9 1.2 D)� V -/v 41 L CITY ECH!p.E el STATE ZIP 9e.we ARCHITEC PHONE NO. ADDRESS CITY STATE ZIP ENGINEER PHONE NO. ADDRESS CITY STATE ZIP CONTRACTORS NAME )C1t/w9*vsr4,w aft.. CITY LIC. NO. P ADDRESS 7 % ��y� /w��/�gPHONE /Wr/ net a.Ig* vine NO. ZIP 9/+Q3 CITY I STATE 2Nt lirnv c,4 PLAN CHECK/PERMIT NUMBER: / / � D'l. CMP USE BLDG. AREA BUR.,AHEA NEW ALDIIION RE —swift tOMaRCIAL ZMr E CMP USE BLDG. AREA AU ENATION E RIPTION OFWORK: iavwwo is v 4 C/42tin Cif 1 tvAxase7--.eel, r � * / REF. A OCC. GIPISI / TYPE(S) OF CONSTRUCTIOF SQUARE FOOTAGE NO. OF STORIES FIRE SPRINKLERS YES NO S=TAATTIISTIC$.C/WSSIFICATIO? �V20 UNIT(S) CODE IKEFFECT C/�� 9R�. y� PLAN CHECK FEE $ ENERGY PLAN CHECK S /0 .2,, VALUATION <ECEIPT NUMBER INITIALS DALE S PLAN CHECK FEE S ENERGY PLAN CHECK $ REVISED VALUATION RECEIPT NUMBER INITIALS DAl E PERMIT FEE $ RETENTION FEE $ SMIP FEE S ACCELERATED FEE S TOTAL BUILDING PERMIT FEE $ 6150 s�/ D, --S) // IC //,t f, et, FEES PAID DIST. PAID DEPT. APPROVAL APPROVAL APPROVAL WASTE APPROVAL D /�](/� _ SCHOOL IIIIIIIII HEALTH ME SANITATION (-] FIRE DEPT. 1—.1 PUBLIC WORKS FEES PD PERMIT OBTAINED r"l SCAOMD i-1 OSHA (-1 INDUSTRIAL L tBBEEI Ly /T - Y�f TIN LS/ IS FE .� 1 \S 1IV 03 C r v_ z 0 m rr^ z INSPECTION DATE INSPECTOR REQUIRED BUILDING INSPECTIONS AND APPROVALS B1 Location and setbacks 82 Sods Engineer's Approval B3 Foundation/Trench forms 84 Structural concrete slab on grade 85 Raised door framing " 86 under floor insulation B? Fist level floor sheathing 88 Second level floor sheathing B9 Third level floor sheathing 510 Rod sheathing -all- Contreleblmca - - - - - --- 1st Grout tilt end Grout IA 3rd Grout Ion - 4th Genet lid 512 Steel framing 013 Fire Dept frame inspection B 14 Building Dept frame inspection 015 Fire sprinkler hangers B16 Insutaeo.Mneather stepping 1317 Interior lath and/or drywall 018 Exterior lath B19 Rated floorcedng assemblies 520 Rated watt assemblies 821 Rated opening protection 522 Rated shaft construction 023 T-bar ceilings 824 Lot drainage 825 Planning Dept Approval B26 Fire Dept Approval 827 Public works Dept Approval B26 Final 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 the Bugling Official, the owner's agent may sign For perm(Is other than the Initial or shell building permit. we the applicant or future building occupant handle a hazardous matenal or mixture containing a hazardous mateial equal t0 or greater than the amount specified on the hazardous materials information guide? Yes or No twit If the answer to the question was yes. will the proposed building or mortified Golly be vathn 1000 feet of the outer boundary of a school? Yes or No twirl I have read the hazardous material hifortnation guide and the SCAOMD permitting cheddtsl 1 understand my requirement under the Slate of California Health and Safety Code Section 25505. 25533 and 25634 concerning hazardous materials reporting Yes Or NO twael NAME SIGNATURE INSPECTION NOTES: "-- 100(D2 / il'/O t-$s percr-to eev mnm