1061-02 - 427 PALM AVE WVERSION 12.2000
OWNER•BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors
LICe0Se Law to eta IOSDwirg reason (Sec. 7031.5, Business and Protrusions Cade:
Any city or minty which requires a perms to construct, alter, Improve, demolish, or
repair any structure. prior to its issuance. also reouires the applicant tor sum permit
to file 8 signed statement that he or she is licensed pursuant to the provisions of the
Contractors License Lew (Chapter 9 (commendng with Sec. 7000) of Div. 3 of the
Business and Professions Code) or Nat he or she is exempt therefrom and the paste
I or the aged exemption. My Ogaden of Sec. 7031.5 by any applicant fora permit
sub' s the applicant to a dull penalty of not more Nan five hundred dollars (5500).):
I. as owner of the Ixoneny, or my employees with wages as their sole com-
pensation. will do the work, and the structure is not intended or offered for sale (sec.
7044. Business and Professions Code: The Contractors Ucense Law does not
ply to an armor of property who builds or improves thereon, and who does such
'ark himself or herself or through his or her own employees, provided Nat saN
Improvements are not intended or offered for sale. If, however, the building or Ion.
provement is sold vntnin one year of completion, the owner -builder will have the
burden a proving that he or she did not build or Improve to the pu1Wse of sale.).
1. as owner of the property, am exdusiyely contracting with licensed con-
tra ors to construct the project (Sec. 7044. Business and Prolessio • • e: The
Contractors Lrcemse new does not Body to an owner a property • s or Im-
proves thereon, and who contracts projects with a contra • . •:rise
pursuant to the Contractors Ucen
0 1 am exempt under :.. B.SP.GYor '.
IItiZ4--o2
Date
n
nature of
LICENSED CO CTORS DECLARATION
1 hereby affirm under penalty 01 ury N 11 am licensed under provisions of
Chapter 9 (mmmendng with Sectl n 7000) of Division 3 of the Business and
Profession Code. and my amn is in till 'circa and ehea.
License Class License Number Espvagn Date
Date Sgnature of Contractor
WORKERS COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the ldlcmi g declarations:
Q Maya and l maintain a certificate of consent to self -Insure for workers'
compensation, as provided for by Section 3700 of the Labor Code. for the per-
formance of the work la which this permit is issued.
I have and will maintain workers' Compensation insurance. as required by
Sec. IW of the Labor (are tor the peramanca of the work fa which this permit
Is issued. My workers compensation insurance carrier and policy number are:
Carver
Policy No.
workers'
[Zv
(IrYxem need id W mrpkeew ..
that in the performance eft
not employ any person In any m inn: so
laws of Catania, of a . 3 iha
pes' compensation
mmpensalion provisions of S:. air r
II N-O wWsi II II ~ !LJ
trone
.
.
nMrW ocean
for .hid, this
become sub)
abor Code
� • be•one
Woe) \
permi s issu
o the workers'
ball l to Ore
all forihwit
Date Signature of Applicant
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE (5 UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TD
CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS ($100aN). W ADDITION TO THE COST OF
COMPENSATION, DAMAGES As PROVIDED FOR l4 SECTION S704 OF
THE LABOR CODE, INTEREST, AND ATTORNEYS FEES
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of pentury Nat there is a oonsinrdion lending agency
for the performance of the work for which this permit is issued (Sec. 3097. Cty. C.).
Lenders Name
Lender's Address
T.
I 'fy that I have read this extra
rid telbat the a e information
Ewi
for
. I agree to comply with all city
to Outing construction. and
upoWhea b)v swooned
ry antes
,py out O e
party f i a lion
41 state laws re -
ot Nis dry
5 /Y
Date Sl ore of Applicant
BUILDING PERMIT
BUILDING SAFETY DIVISION.
COMMUNITY. ECONOMIC & DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo, CA 90245
I Redueslllne: (3101524-.
SITE ADDRESS
)C 427 14 . PAS h\J -
SUITE f IDENTIFYING NUMBER
ASSESSOR PARCEL NUMBER
BOOK PAGE
PMGEL
APPLICANT 1 CONTACT PERSON
? •k d� (nt'[�02.
DATE
I. , • ..
I
ADDRESS
1225 $rg`f 2-1 i
• H •
IA
' rr 5j.f
CITY
5AN �j l l',.
s E
race
PROP • ,�
�
PH NNO.
two
9
ADDRESS
CITY
'.l, S 141/4/v�
STATE
CA—,
ZIP
6110:2z45
ARCH
PHONE NO.
'DRESS
CITY
STATE
ZIP
ENGINEER
`% b tftut STin J5
PHONE NO.
?w 7 t t
ADDRESS
7 LO WI LSF4t tt.E $(,Vb
2 0
CITY (,1 /�
441 I •
STATE
CA—•
ZIP
dfl,4ol
ITV LIC. N0.
CONTRACTORS NAME .
)1VA '4IAI.t kt,
AS
PHONE NO.
CITY
STATE
ZIP
PLAN CHECK/PERMIT NUMBER: / O (c
/-b 2
tMP USE
bWU. AREA
1
NEW
RESIDENTIAL
'OOMMf�EFi IAL
LMP USE
kLUU. AREA
AUDITION
LAP USE
BLUE. AREA
ALTEI4A !II
X,,
DESCRIPTION0
Xc ReMoD
�WOORK: y�r
�4/ITNW
see *M0
t)C i . --
+72 . /6 6 �-si
eiSo • at)
Iz5;.5 b
-'— 2.'I2*•ZS
rb
RE . #
OCC G UP(SI
le-S
TYPES F NSTRUCTu)T
V°D7
UA!R�E/F���jjTAGE�
�`A �+� �l
NO. OF STORIESI
1
FIRE SPRINKLERS
YES NO
ST T TICAl.CL9551FICATIIX
(-3J19O
UNIT(S)
CODEaEFFEC//T�
$
$
q/ '/\
48 •%�]U(y, 743
$ X�f�7io.61
46-PLAN CHECK FEE
ENERGY PLAN CHECK
VALUATIGN
CW.'88'
'RECEIPT NIALIE(t i _ rt,
!
/lEVI
INITI 6 D1y'W,x
T/C
DA 0..." __�
PLAN /FEE $ -41
CHECK�d7 $
/ �
5FVEVI ATION
VNERGY
/ �+
0Z-73) -/ 3 .
RECEIPT NUMB R
INITIALS
DATE
LL I PERMIT FEE $
/J /( RETENTION FEE $
SMIP FEE 1 $
ACCELERATED FEE S
/
TOTAL BUILDING PERMIT FEE S
/4C_.�/I�gy0'-i`//
• v`-'�
�/R/I3
2 / .((/3 2—
---/1�`
/�/.5 #6/T/ C
• 86. / 0
FEES PAID
DIST. PAID
WORKS FEES PO
PERMIT OBTAINED
DEPT. APPROVAL
APPROVAL
APPROVAL
WASTE APPROVAL -
SCHOOL
_ HEALTH
MM SANITATION
FIRE DEPT.
r1 PUBLIC
j—j SCAOMD
I —1 OSHA
rl INDUSTRIAL
F1ETi M@�R /� /
/
INITIALS�
aX /0�
.TINALEU Y (i
DAIr
. a
NO.
INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
81
Location and setbacks
82
Soils EnlYneets Approval
133
Foundition/trench Inns
84
Structural concrete slab on grade '.:
85
Raised Moor barring •
1Z-,0„,Zj
(/✓
BB
under foor :mutation
87
First level floor sheathing
BB
Second level Boor sheathing
sheathing
Toro levelshed
/��/�/{y..{////%
fr%r
B4O
1
thgcor
Root sneaking
1'' y o.3
811
Concrete block
( P r „ set
1st Grout loft
2nd Greta fit
3rd Grout sit
4th Grout eft
812
Steel framing
813
Fre Dept frame inspection
81a
Building Dept. frame inspection
„�
�s(f
' /2
�1_/
-1 `�-I
815
Fire sprinkler hangers
6
817
stri
net
nr�
-G �f r C
Biz
Interim lath andlIX drywall—_^+
Iona anger drywall
:,.
AP
%`',
" 'I%i11
818
Exterior lath
✓ri —(7
810
Rated ltoor/Celfng assemblies
'
820
Rated wall assemblies
B21
Rated opening protection
822
Rated shaft mmstmcton
823
Tear ceilings
824
Lot daiage
825
Planning Dept Approval
826
Fire Dept Approval
827
Public Works Dept Approval
828
Final Building Inspection approval
DESCRIBE COMPLETELY THE INTENDED USE OF ALL SPACE APPLICABLE TO THIS BUILDING PERMR:
The following statement must be signed by the Building owner.
(When approved by the Bufid mg Official, the owner's agent may sign for permits other than the Initial or shall building permit
We the applkaM IX future WON occupant handle a hazardous material or mixture containing a hazardous material equal to or greater than the arnpaa
specified on the hazardous mate.eb information guide? Yes or No lost
If the answer to the question vas yes, wl the proposed Wid'ng or modified fa cNy be vMhn 1000 feet of the outer boundary of a school'!
Yes or No emu
I have read the hazardous material information guide and the SCAOMD permitting cheddisl I understand my regriertant under the State of California
Health and Salegl€ode Section 25505.25533, and 25634 concerning hazardous materials reporting_ Yes or No teem
•
SIGNATURE
OTES:
bssrefrcttlnt fit9`4G-C
R.. mrod