HomeMy Public PortalAbout6229 OAK AVE_Building__ . -� -: •. p/-�_Twp, pwV. • . , pF� R�sw•,.
SA688A CE*808.10.56.APPLICATIOtli FOR BUILDING- PERIV!•I o;
BUILDING AND SAFETY DIVISION' BUILDING
ADDRESS
Pepartment Of County Engine! _ - `•�
County Of LOS Angeles LOCALITY
JOHN A.LAMBIE. COUNTY ENGINEER NpREST
CASSATT D.GRIFFIN.SUPT OF BUILDING CROSS ST.
DISTRICT NO. GROUP PE r SEWER MAP..
FOR APPLICANT TO FILL IN ; K P
^ q u �^
coBUILDING
ADDRESS G7 d a q K• <yn I C .h
8TATIST16AL CLASSIFICATION
CLASS. NO: DWELL. UNIT
LOT NO. BLOCK MAP STATE
NUMBER HWY YES NO
TRACT USE ZONE SPECIAL
U I NO.OF.BLDGS. ! CONDITIONS 7+Qy
SIZE OF LOT NOW-ON LOTIf
USE OF � •/b•a
EXISTING BLDG. �I(� }® BUILDING' 1ST.
�1 SETBACK YARD HWY STREET NAME, WIDTH
OWNER j� b�7 � I FRONT
MAILADDRESS'�) 15 1 1.l �I S SIDE
■+
CITY �• N..L
ARCHITECT OR �p TEL. IIITSPECTION RECORD
ENGINEER li NO.
ADDRESS -
TEL
CONTRACTOR ( i NO. 619
r f
ADDRESS. 0'
DESCRIPTION OF WORK /-71-R(•+ DWi,;', •.,P ,t t
NEW-) ADD ALTER REPAIR DEMOLISH _ r
FT. ` NO.OF NO.OF •� -�s 7 /%%Y
_ ) "
SIZE J STORIES. FAMILIES I) /� r
USE OF STRUCTURE CJ /. I' AllAIC, h/,'7l'
'SiC en a e &O APPROVALS IY7inJP- t� I�G✓7
SIGNATURE OF
APPLICANT DATE INSPECTOR'S SIGNATURE
ADDRESS
FOUNDATION:LOCATION. r '^/�•�r�► VGT
FORMS. MATERIALS
RAME: FIRE
FEE• $ FBRACING.BOLTSS
FURNACE: LOCATION. ry /y h �l'! ,
VALUATION �- $ ='- GAS VENT.DUCTS
- .`l4ti(_Ia"k('�
FEE A
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH. INT.
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND 7, (1
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND LATH. EXT. v
STATE LAWS REGULA ING BUILDING OIVST CTION.
OF HOUSE NUMBER.COR-
SIGNATURE G. '
RECT AND POSTED
PERMITTEE
ADDRES FINAL
OHN A.-LAMBIE.COUNTY ENGINEER. -~ LLYDE N. DIRLAM.PRINCIPAL STRUCTURAL ENGINEER
PLAN CHECK VALIDATION K. -M.O. CASH PERMIT VALIDATION • 'CK. M.O. CASH
3 5 2 1 OCT 1-8 1.6 1 1 .7.5 1 /
3 63 4 -0CT2 2 .1 -2 .3-.5 0 M
79A93— CE#903 9-67 U
.APPLICATIO FOR BLdLDING PERMIT LI
COUNTY OF LOS. ANGELES BUILDING /
DEPARTMENT-OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY `
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUPT OF BUILDING NEAREST. -
CROSS
EAREST. -CROSS ST.
PEXISTING
APPLICANT TO FILL IN
DISTRICT NO CO ST P D BY
(Print or type only) `V s t
STATISTICAL CLASSIFICATION SEWER MAP
� CLASS NO. �DWELL.UNITS BI�
BLOCK U ONE MAP D
NO.
JSPECIAL
UV CONDITIONS PP
NO.OF BLDGS.
NOW ON LOT
._
BLDG.SETBACK FROM
TE�� ) 7�7, FRONT PROP.LINE OF - (STREET).
OWNE NO. (� TYPE OFEXISTING SETBACK HIGHWAY + YARD = TOTAL
HI HWAY WIDTH. FROM C.L.
ADDRESS yZ (- �s•�
CITY Z d + '�C
BLDG.SETBACK FROM (STREET)
ARCHITECT O TEL. SIDE PROP.LINE OF
ENGINEER' NO. TYPE OF EXISTING SETBACK HIGHWAY + YARD =f TOTAL
ADDRESS HIGHWAY WIDTH FROM C.L.
TEL _ ry + = d
CONTRACTO NO. d t
D ` NO. CORNER CUTOFF YES ❑ NO
CITY CLASS SEI;REVERSE SIDE FOR SPECIAL APPROVALS t3
DESCR TION OF WORK o
E ADD ALTER REPAIR DEMOLISH ..-
•S .- FT. NO. OF NO. OF
SIZE J STORIES FAMILI
USE OF
STRUC URE
SI NATURE OF
APPLICANT -
VALUATION$ v .„
APPROVALS DATE INSPECT.OR'S SIGNATURE
P.C. PMT. �`� FOFORMS I MATERIALS ON
FEE$ FEE$
FRAME: FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING, BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
BUILDING CONSTRUCTION. 1 CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH, INT.
TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT-
ING TO WORKMEN'S COMPENSATION INSURANCE.. -
7y/��' `^'_ LATH, EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTEE RECT AND POSTED
ADDRESS FINAL 6 �/ {
JOHN F. LEWIS. PRINCIPAL STRUCTURAL ENGI R
PLAN CHECK VALIDATION CK. M.O. CASH _ q PERMIT[ypVALIDATION CK. M.O. CASH
LNAJ 4. 4 ..6. 0� APR 2.J. ,. f3- :.� .O N•
.76A68.SA.CE#QOS
APPLICATION FOR BUILDING PERWT IUI
:COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY'ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, COUNTY ENGINEER LOCALITY M
COLEMAN W. JENKINS, SUPT OF BUILDING NEAREST
CROSS ST. `Q j- e_P,6A/
REXISTING
R APPLICANT TO FILL IN DISTRICT NO^� G OUP TYN T PFFRCESSED BY
(Print or type only) �J/Q tf 'lji"
STATISTICAL CL SSIFICATION SEWER MAP
CLASS NO.-j- '- DWELL.UNITS P
,�ao S 4 C? p�y SO
BLOCK USO E MAP
NO.
1-14A-A7 IAL
CONDITIONS.SPEC
NO.OF BLDGS.
NOW ON LOT
DG. �'' BLDG.SETBACK FROM
TEL FRONT PROP.LIN 67 (STREET):
OWNE NO. IjZQ•�s7/� TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL
ADDRESS 4 yZ ""v. HIGHWAY WIDTH FROM C.L.
CITY 1 c C// 61',11 1 4-
BLDG.
BLDG.S BACK FROM (STREET)
ARCHITECT O L.TESIDE PROP.LINE OF
ENGINEER NO. TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL
ADDRESS /�1' -yam HIGHWAY WIDTH FROM C.L.
TE
CONTRACT J9/_3 E- NOL,R 'IS vp + - a'
ADDRESS 1/ 3 F v7P/W&.r W&. CORNER CUTOFF YES ❑ NO C.3
CITY CLASS SEE REVERSE SIDE FOR SPECIAL APPROVALS
DESCRIPTION OF WORK L"
D_
N
Z
NEW ALTER REPAIR DEMOLISH
SQ. FT. y O. OF NO. OF
SIZE TORIES FAMILIES
USE OF
STRUCTURE• a✓1�
/
SIGNATURE OF
APPLICANT
VALUATION$ Ell
APPROVALS DATE INSPECTOR'S SIGNATURE
P.C. PMT. CJ FOUNDATION: LOCATION
FEE$ FEE$ f FORMS, MATERIALS
FRAME: FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT, DUCTS '
BUILDING CONSTRUCTION. 1 CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLA-
• TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT-
ING TO WO OMPENSATION INSURANCE.
LATH, EXT.
SIGNATOR O -MOUSE NUMBER COR-
PERMITTEE RECT AND POSTED
ADDRESS FINAL
JOHN F. LEWIS. PRINCIPAL ST RAL ENGINEER
PLAN CHECK VALIDATION cK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
0" 5813.;S AUG 8 1 D 6.oQ,-
II
COMM OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETi / LAND DEVELOPMENT
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID:
NO: SEWER MAP BOOK: PAGE:
NO. 0£
CONS
ON FILE
SQ. FT
STORIES
TYPE
00
STRUCTURE: 852
1
V -B
ASSESSOR INFORMATION NUMBER:
GARAGE:
N0.
OF FAMILIES:
5385-001-018
OTHER: 23
1
V -B
0
NO
21
TENANT:
IEXIST BLDG USE:
IEXIST OCC GRP:
SCHOOL WITHIN HAZARDOUS
OWNER: TEL. NO: IBLDGS. NOW ON LOT:
TAI, FIONA
1842 S CALIFORNIA ST
SAN GABRIEL CA 91776 1
(FEE DESCRIPTION:
APPLICANT: TEL. N0: 1
SAME AS OWNER - 1131 PLANCHECK W/ENERGY
IAA BLDG PERMIT ISSUANCE
IAB STATE GREEN BLDG FEE
IAC STRONG MOTION RESID
IB2 PERMIT W/ENERGY
CONTRACTOR: TEL. NO: IE1 PC EXTENSION FEE 25k
SAME AS OWNER - 108 CERTIF OF OCCUPANCY
LIC. NO I
ARCHITECT OR ENGINEER: TEL. N0:
SUN, STEVE (626) 262-9668-
4028 ROSEMEAD BLVD. #35 LIC. NO:
PICO RIVERA CA 90660 NONE
MAP
NO: SEWER MAP BOOK: PAGE:
FIRE ZONE:
CMP:
3
00
N0.
OF FAMILIES:
DWELLING UNITS:
APT/COND: STAT
CLASS:
0
NO
21
SCHOOL WITHIN HAZARDOUS
AIR
QUALITY:
1000 FEET
MATERIALS
NO
NO
NO
1) WORK DOES NOT COhS1ENCE, OR
2) WORR IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
* ADDITIONAL LATA ON FILE
ID: DPR261
bR�9 oR K
BUILDING PERMIT
RESIDENTIAL ADD/ALT/REP
HL 0508 1504130025
NEW BUILDING ADDRESS:
OCCUP GROUPI 6229 OAK AV
R -3I TEMP CA 917801656
NEAREST CROSS STREET:
U THOMAS PAGE: 596 GRID: J2
LOCALITY:
ISSUED ON: PROCESSED BY:
104/27/16 SR
126,000
TEMPLE CITY
I1 -STORY SFD ADDITION AND REMODEL. INTERIOR REMODEL 775 SF.
QIIANTITY: UOM: AMOUNT:1488 BE. ADDITION OF LIVING ROOM, OFFICE, BEDROOM AND 2 BATH
(ROOMS. CONVERT EXISTING 364 SF. GARAGE TO BEDROOM AND SATHRO
126000.00 VAL 1,365.40 1
34.40 ISPECLAL CONDITIONS:
126000.00 VAL 6.00 1
126000.00 VAL 16.40
126000.00 VAL 21001.00
341.35 DOL 341.35 (APPROVALS DATE INSPECTOR SIGNATURE
125.80
TOTAL FEES 3,890.35 (LOCATION AND SETBACKS
I
(SOILS ENGINEER APPROVAL -
(SMOKE ➢ETECTION DEVICES
I
(FIRE DEPARTMENT APPROVAL
I
ROUTE T0: BS 0508
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects 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 compensation, will do (-/)all of or U portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
(, I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the pwject (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant to the Contractors' State License
Law).
(,: I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prior) to oompletiogI of the improvements covered by
this permit, I Wnnot legally sell[ a structure that I have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: htto:!/www.leainfo.ce.gov/calaw.html
Date: ! I
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S 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 Professions Code, and my
license is in full force and effect
License Class License
Date Contractor Signature
WORKERS' COMPENSATION DECLARATION
WAF�NINO: FAILURE TO SECURE WORKERSCOMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
1 have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
JOB ADDRESS -
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
mateHal or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes
El No ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirementsunder the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑
I declare that
notification
of asbesfos removal is not
applicable to
addressed
project
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
Name of Agent Phone Number I hereby affirm under penally of perjury that th
ere is a
I certify that, in the performance of the work for which this Construction lending agency for the performance of the work for
permit is issued, I shall not employ any person in any manner which this permit is issued (Section 3097, Civil Code).
so as to become subject to the workers' compensation laws of Lenders Name
Califomia, and agree that, if I should become subject tothe
workers' compensation provisions of Section 3700 of the Labor Lenders Address
Code, I shall forthwith comply with those provisions
Signat
By my signature below, I certify toeach of the following:
of � Date �� 6
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applica
nt (Print Name) Applicant Signature
Company Name Date
!
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signa i of Pro arty Owner or Auth
orized Agent
Date —7r7 — � rrl,�
1) 410RK DOES NOT COM4ENCE, OR
2) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
REPORT ID: DPR261 RODTE T0: BS0508
I � I
15MOKE DETECTION DEVICES 1 I
COUNTY OF LOS
ANGELES
TEMPLE CITY
#
0508
BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS
9701 LAS TUNAS
NEW RESIDENTIAL
BUILDING AND SAFETY / LAND
DEVELOPMENT
TEMPLE CITY CA 91780
BL 0508 1504130024
PHONE: (626) 285-0488
EXT:
ILEGAL ID:
NO. OF
CONST
NEW
BUILDING ADDRESS: 1
ON FILE
SQ. FT STORIES
TYPE
OCCUP GROUP( 6229 OAK AV
ISTRUCTURE: 0 1
V-B
R-3
TEMP CA 917801656
(ASSESSOR INFORMATION NUMBER:
GARAGE: 495 1
V-B
U
NEAREST CROSS STREET: 1
15385-001-018
I
OTHER:
THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY CAI
I
(TENANT:
USE ZONE: R-1
(ISSUED ON: PROCESSED BY:
104/27/16 SR 1
(OWNER:
TEL. NO:1BLDGS.
NOW ON LOT:
VALUATION:
IFINAL DA E FINAL BY CODE: 1
ITAI, FIONA
26,000.
q
11842 S CALIFORNIA ST
1
/C
(SAN GABRIEL CA 91776
FEES
PAID
IDESCRI LION F WORK 1
IBUILD NEW DETACHED 2 CAR GARAGE
IFEE DESCRIPTION:
QUANTITY:
GUM:
AMOUNT:1
(APPLICANT:
TEL. N0:
ISAME AS OWNER
-
ID1 PLANCHECK W/O EN-HC
26000.00
VAL
411.90
1
IAA BLDG PERMIT ISSUANCE
34.40
ISPECIAL CONDITIONS:
IAB STATE GREEN BLDG FEE
26000.00
VAL
2.00
IAC STRONG MOTION REBID
26000.00
VAL
3.40
ID2 PERMIT W/O EN-HC
26000.00
VAL
602.50
ICONTRACTOR:
TEL. NO:
1E1 PC EXTENSION FEE 25%
102.98
DOL
102.98
(APPROVALS DATE INSPECTOR SIGNATURE 1
ISAME AS OWNER
-
I TOTAL FEES
1,157.18
I 1
1
LIC. NO
1
AND SETBACKS L
1LOCATION
ISOILS ENGINEER APPROVAL 1
(ARCHITECT OR ENGINEER:
TEL. NO:
(FOUNDATION/TRENCH FORMS
(SUN, STEVE
(626) 262-9668-
14028 ROSEMEAD BLVD. #35
LIC. NO:
FLOOR I 1
IPICO RIVERA CA 90660
NONE
i
1SLAB/UNDER
1
(RAISED FLOOR FRAMING I I I
MAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMP:(
(UNDERFLOOR INSULATION
1
3 001
I
I
(1ST LEVEL FLOOR SHEATH 1 1
IND. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
I
I
0
NO 12
1
12ND LEVEL FLOOR SHEATH
SCHOOL WITHIN
HAZARDOUS
IROOF SHEATHING
AIR QUALITY: 1000 FEET
MATERIALS
I NO NO
NO
(FIRE DEPT. FRAME INSPECT
1) 410RK DOES NOT COM4ENCE, OR
2) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
REPORT ID: DPR261 RODTE T0: BS0508
I � I
15MOKE DETECTION DEVICES 1 I
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects- the applicant to.a civil.
penalty of not more than five hundred dollars ($500).):
U I, as owner of the properly, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
(, I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contr9 or pursuant to the Contractors' State License
Law),
Us I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prior) to compleboryry of the improvements covered by
this permit, Icannot legally sell a structure that I have built as an
owner -builder if It has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: htto://www.leginfb.m.ciov/calaw.htmi.
Signatureopert�yer or Authorized Agent
LICENSED CONTRACTOR'S 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 Professions Code, and my
license is in full force and effect.
License Class License
Date Contractor
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERSCOMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions /
rd
Signat eof Applicant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
aII persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Pont Name) Applica
nt Signature
Company Name Date
JOB ADDRESS - -
LOCALITY
HAZARDOUS MATERIAL DECLARATION
WiII the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modfication from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ Ro ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requiremgnts
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency forthe performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I cerfrfy to;each of the following:
I am the property owner or authorized to act on the
property owners behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature ofSignature of Property weer or Authorized Agent
or Authorized Agent