1024-02 - 223 RICHMOND STVERSION 12-2000
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors
License Law tor the tdlowing reason (Sec. 7031.5. Business and Professions One:
My city or county which requires a permit to construct, alter, improve, demolish, or
repair any structure, prior to Its issuance, also termites the applicant tor such permit
to fie a signed statement that he or she is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Sec. 7000) of Div. 3 of the
Business and Professions Code) or tnal he or she is exempt theretrcm and the basis
for the alleged exemption. My violation of Sec. 7031.5 by any applicant for a permit .
the applicant to a civil penalty of not more than Five hundred dollars ($500).):
I, as owner of the property, or my employees with wages as their sole corn -
will do the work, and the structure is not intended or offered for sale (Sec.
Business and Professions Code: The Contractors Ucense Law does not
apply to an Owner of property who builds or Improves thereon, and who don such
work himself or herself or through his or her own employees, provided that such
Improvements are not intended or offered for sale. II, however, the building or im-
provement is sold Within one year of completion, me ownar,butlder will nave the
burden of proving that he or sne aid not build or Improve for the purpose of sale.).
I, as owner of the property. am exclusively contracting with licensed con-
ba ors to construct the project (Sec. 7044, Business and Professions Code: The
Contractors License Law apes riot apply to en owner d property who Wads or im-
proves thereon, and who contracts for such projects with a contractor(s) license
pursuant to the Contractors License Law.).
Q I exempt under Section B.&P.C. for this reason
/earn
�1(
tet), owner
L D
I hereby affirm under penalty
Chapter 9 (commencing with Secti
Professions Code, and my li
CONTRACTORS
of perjury
nse is
DECLARATION
that I am licensed under provisions of
7000) of Division 3 of the Business end
n wit torce and effect.
License Class
Li n umber Expiration Date
Date Signature of Contractor
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
I have and wilt 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 for which this permit is Issued.
El I have and Will maintain workers' compensation insurance, as required by
Sec. .1]00 of the Labor Oyu. tor the penonnance or the work tor winch this cermit
is issued. My workers' compensation Insurance carrier end policy number are:
Caner
Policy No.
I
compensation
wok
71.,fn
(ens swoon teed mr ere m�yaea i dw pane w tm ow roved amrs d i rot w ws+l.
I certify that In the performance of the work for which this permit Is Issued,
a I no mploy any person in any marcher so as to become subject to the workers'
laws of California, and agree that it I should become subject to the
rs pensa' ' one of 3700 of the Labor Code, I shall forthwith
. pga on
1(AY!/h
l e E W Applicant
WARNING: FAILURENLAL.O SECURE LLTSBTAMPENSATION
PLOYER
COVERAGE CRThSUBJECTI$ENLAWWLADDSMALLUP ONEHULDREDN
SNAL PENALTIES AND 000)L NADS TI TO ONENTOT HUNDRED
CTON3TCF
COSTO
THOUSAND DOLLARS AMA(55 AS RONADQFOR IN SECTION
COMPENSATION. O DAMAGESASPROVIDED TTOINEY'S EE]]Oa OF
THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of periury that there is a construction lending agency
for the performance of the work for which Ws permit is Issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address -
correct.
f
m
I candy that
I agree
bull'lin
era
topt3*oficentor"
I have read this appbtion and state that the above information is
to comply with as city� eaenvd county ordinances and slate laws re-
consNldieL and h authOnze re la 0 S OW
a eboweygYnlrtlt
Arent
BUILDING PERMIT
BUILDING SAFETY DIVISION
COMMUNITY. ECONOMIC .3 DEVELOPMENT
SERVICES DEPARTMENT
350 Main Street
El Segundo, CA 90245
•
SITE ADDRESS
22 5 «1 efrlin --c 4
UITE / IDENTIFYING NUMBER
ASSESSOR PARCEL NUMBER
PAGE PARCEL
BOOK
APPLICANT/CONTACT
)61.-aS('
P RSON
6&D
DATE
Xo ' A -O—
DDRESS
131e1
r
h _U
PHONE NO.
110 350a/1
CITY/$` !!1y1//II__
STATE
Carr
ZIPP0/ �4��J
PROPI:RrY 04141
PHONE NO,
ADDRESS
CITY
STATE
ZIP
ARCHI FECT
PHONE NO.
ADDRESS
CITY
STATE
ZIP
ENGINEER
PHONE NO.
ADDRESS
CITY
STATE
ZIP
CON tRRACCTORS NAME
p�
I �/��={//7
CITY LIC. NO.
SS
PHONE NO.
CITY
STATE
ZIP
PLAN CHECK/PERMIT NUMBER: \ h - 01/r
1 Y
LMP USE SLUG. AREA
(SLUG.
NEW
RESIDENTIAL
tMP USE AREA
AUDIRCN
COMMERCIAL
LMP USE LUG. AREA
ALI ERATION
DESCRIPTION OF WORK:
cZ5 ‘ ptnC
()Nib
6n aft
5il
it
/
REF. a
OCC. GitOUP(S)
(YPEISI OF,CONSTRUCTIOt
SQUARE FOOTAGE1S
2l°
NO. OFFF4STORIES
l
FIRE SPRINKLERS
YES 01
STATISTICAL CLASSIFICATIOt
NO
UNIT(S)
_
CODE IN E
Zoo
1�y♦}U
$�
/NCHECK FEE $
ENERGYP N[C CK $
Isrl
/6�t(Gy.
p
wV'1
VATI
3ED—I l
'RECEIPT NUMBER
INITI
DATbAD
$
$
\ I 1
�(I/'�1/ J(,/�s—
$
PLAN CHECK FEE
ENERGY PLAN CHECK
REVISED VALUATION
RECEIPT NUMBER
INITIALS
DATE
vPERMIT FEE $
RETENTION FEE $
SMIP FEE D $
ACCELERATED FEE $
TOTAL BUILDING PERMIT FEE $
ea26't1
/✓ r✓/,V
A .60
/1
RSV" I
PAID
PD
F
DEPT. APPROVAL
APPROVAL
APPROVAL
WASTE APPROVAL
_ SCHOOL FEES PAID
_ HEALTH
SANITATION DIST.
FIRE DEPT.
r"j PUBLIC WORKS FEES
r1 SCAQMD
r1 OSHA PERMIT OBTAINED
I —"I INDUSTRIAL
RECEIPT NUMBER
INITIALS
DATE J /k _ S
UV J
}WALED BY
DATE
NO.
INSPECTION
DATE
INSPECTOR
REQUIRED BUILDING INSPECTIONS AND APPROVALS
SI
Location and setbacks
B2
Soils Engineers Approval
B3
Foundatio&Trnch forms
B4
Structural concrete stab on Made
85
Raised boor framing
86
Under axe insulation
BT
First level lbor sheathing
. Y
BB
Second level floor sheathing
..
Bg
Third level foor sheathing
B10
Roof sheathing
B11
Concrete bbcte
1st Grout ift
n
2ndGmut tit. ,
3rd Grout Eft
4th (rout NI
1312
Steel framing
1313
Fire Dept frame inspection
614
BuWng Dept frame Inspection
B15
Fire springier hangers
BIB
InsulationMnether sbppng
B1 T
interior talh and/or drywall
B18
Exterior lath
Big
Rated floor/CMingassem6fes
B20
Rated wall assemblies
B21
Rated opening protection
022
Rated shaft construction
B23
T-bar ceilings
824
Lot drainage
825
Planning Dept Approval
B26
Fire Depl. Approval
827
Pubic Walks Dept. Approval
B28
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 Bucdng Official, the omer'a agent may sign for permits other than the Initial or shed building pemnt
win the appkant or future bulldog occupant handle a hazardous material or rNalure containing a hazardous material equal to or greater than the amount
specified on the hazardous malanalS MgnlaeM guide? Yes or No 1aa.1
If the answer to Me question was yes. vie the proposed building or modified tacitly he within 1000 feet Of the outer boundary of a s0o017
Yes or No won
I have read the hazardous material Information guide and the SCADMD permitting rhecidst I understand my requirement under the Stale of California
Health and Safely Code Section 25505. 25533. and 25634 concerning hazardous materials reporting Yes or No loral
NAME SIGNATURE
INSPECTION NOTES:
Rim M1N
August 26, 2002
City of El Segundo
Building / Planning Departments
To whom it may concern,
I, Gordon T. Stevens, represented as property manager for Mrs.
Bernstein, owner of the commercial real estate parcel located at
223 Richmond street in El Segundo, CA., do hereby give Mr. Scott
Reed, assigned legal tenant of said property, authority to obtain
all necessary permit(s) for property renovations.
Please do not hesitate to call me if you need further assistance
with this matter.
vr i�tilirtr
r de/
or on T. Stevens
515 California Street
El Segundo CA, 90245
310 322-2168