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Home My Public Portal About6229 OAK AVE_Electrical__ FHAGGB.CE806-6-37 APPLICATION FOR ELECTRIC PERMIT; 1 COUNTY OF LOS ANGELES. DEPARTMENT OF COUNTY ENGINEER BUILDING f BUMDING AND SAFETY DMSION . ADDRESS JOHN A.LAMBIE,COUNTY ENGINEER CASSATT D.GRIFFIN,SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN CROSS ST. PERMIT FEES LIGHTS RECEPTACLES SWITCHES OWNER NUMBER ITEM EACH I FEE MAIL TOTAL OUTLETS $ ,10 $ C ADDRESS ELEC, RANGES, WATER HEATERS, CITY TEL.NO. CLOTHES DRYERS .50 D ELEC. SPACE HEATERS, STAT'Y. COOK- ELECTRICIAN I ING UNITS, GARBAGE DISPOSERS, �+ ADDRESS / AUTO WASHERS, DISHWASHER .25' d LIGHTING FIXTURES .10 d9e> CITY TEL.NO. MOTORS STATE � y LICENSE NO.. i+ HORSEPOWER 'DISTRIC O. GR H.P: OVER INC. O W READY FOR INSPECTION site a LEBO .25 I — 2 .so INSPECTION RECORD 2 5 1.00 .5 18 f.sa is so 2.50 50 200 5.00 .7 .'r lox SIGNS I NO.TRANS NO.LAMPS -SERVICE O-600V 1.00 ®a ' SERVICE OVER 600V 5.00 WIRING PERMIT 1.00 a FIXTURE PERMIT 1.00 0 SUPPLEMENTARY PERMIT 50 TOTAL FEE APPROVALS $ DATE INSPECTOR'S SIGNATURE 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP ION �y �r AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY CONDUIT Z-1 R t7WITH ELECTRICAL WIRING,COUNTY ORDINANCES AND STATE LAWS GULATING WIRING ��-zS S"� •Yj;/;f;'^ +I f / I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES / IS"1 !�`r!/4►/1Yr?�l.� LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF I CALIFORNIA OR THAT I AM THE LEGAL OWNER .OF THE ABOVE POWER DESCRIBED RESIDENTIAL PRO SIGNATURE UTILITY CO.NOTIFIED OF PERMITTE r - , i .. FINAL ® / .{�] !.'v ". . if IOHN A.LAMBIE. VALIDATION ARTHUR C.VEIT, ' ►OUNTY ENGINEER CK Mo cases F;ESUPERVISING ELECTRICAL ENGINR +Q4 5 6 2&; NOV 25 2 7.35 M �r "IA.M-cE.oea:s. APPLGCATEON FOR ELECTRIC PERMIT 1 COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING /f . BUILDING AND SAFETY DIVISION ADDRESS J JOHN A. LAMBIE, COUNTY ENGINEER CASSATI'D. GRIFFIN,SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST PERM FEES CROSS ST. 1 ITEM NUMBER I EACH FEE OWNER ` OUTLETS: �j $ $ MAIL LIGHTS RECEPT. SW. G� SID ADDRESS LIGHTING FIXTURES .10 CITY TEL.NO. ELEC.RANGES CLO.DRYERS ELECTRICIAN WATER HEATERS . .50 ADDRESS ELEC.SPACE HTRS. DISHWASHERS CITY TEL,NO. GARBAGE DISPOSERS AUTO.- STATE WASHERS STA.COOKING UNITS 1 .25 LICENSE NO. MOTORS: OVER INC. H.P. DISTRICTNO. IGUWP ZONE P BY 0- I/z 1 1 .25 I�A— 2 .50 INSPECTION RECORD 2— S 1.00 1.50 Is— 50 2.50 So—200 5.00 SIGNS: NO.TRANS. NO.LAMPS SERVICE 0-600V 1.00 SERVICE OVER 600V 5.00 MISC. WIRING PERMIT 1.00 Q ' FIXTURE PERMITL.00 0 SUPPLEMENTARY PERMIT q::� TOTAL FEE $ 1 HEREBY.ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE '- AND STATE. THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALI. COUNTY ORDINANCES AND STATE LAWS REGULATIN3 CONDUIT �-•`� - ELECTRICAL. WIRING. WIRING ��A � /•ri� �� I�� 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED Y OS ANGELES COUNTY AND STATE OF FIXTURES CALIFORNIA OR TH 1 THE LEGAL OWNER OF THE ABO DESCRIBED RESID I OPERTY. POWER _ SIGNATURE UTILITY CO.NOTIFIED OF PERM -m �._FINA6qq SU ERVISING ELLECTRICAL ENGINEER _ �,,8 8 1 8 r7c2:'4 2 A2.55 M COUNTY OF LOS AtNGELESr DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT ILEGAL ID: ON FILE (ASSESSOR INFORMATION NOFffiER: 15385-001-018 (TENANT: I I (OWNER: TEL. NO: TAI, FIONA (626) 283-1932- 11842 S CALIFORNIA ST ISAN GABRIEL CA 91776 I APPLICANT: TEL. N0: SAME AS OWNER - CONTRACTOR: TEL. NO: SAME AS OWNER ELECTRICAL PERMIT - LIC. NO EL 0508 1604270023 TEMPLE CITY CA 91780 ARCHITECT OR ENGINEER: TEL. NO: SUN, STEVE (626) 262-9668- 4028 ROSEMEAD BLVD. #35 LIC. N0: PICO RIVERA CA 90660 NONE PERMIT EXPIRES 180 DAYS IF 1) WORK DOES NOT COMMENCE, OR 2) WORK IS SUSPENDED OR ABANDONED, OR 3) FAILS TO OBTAIN CODE REQUIRED INSPECTION TEMPLE CITY # 0508 ELECTRICAL PERMIT 9701 LAS TUNAS EL 0508 1604270023 TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: FEES PAID BUILDING ADDRESS: 6229 CAN AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917801656 I NEAREST CROSS STREET: Al PERMIT ISSUANCE FEE 34.40 THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY E1 TEMP SERV POWER POLE 1.00 TMP 54.20 TOTAL FEES 88.60 (ISSUED ON: PROCESSED BY: PLAN BY: 104/27/16 SR (FINAL PATE FINAL CODE: ID: DPA265 ROUTE T0: HSO508 TEMPORARY POWER POLE 1APPROVALS DATE INSPECTOR SIGNATURE I TEMPORARY POWER POLE J UNDERGROUND CONDDIT I I UFER GROUND (ROUGH CONDUIT (ROUGE WIRING (MAIN WATER LINE (PLASTIC Y/N METAL Y/N 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, atter, 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 property, or my employees with wages as their sole compensation, will do (J) 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 wRh 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 Con" or 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 priorlto completiorp of the improvements covered by this permit, I cannot 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: httpi/ANww.leginf6.ca.gov/mlaw.htmi. Date:��LV 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 WARiJING: 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 s 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 Agent Phone Number I certify that, in the performance of th e 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 nature ofApplilcant DatIVe 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. Applicant (Print Name) Applicant Signature Company Name Date JOB ADDRESS - LOCALITY HAZARDOUS MATERIAL DECLARATION Will 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 She 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 ❑ No ❑ i I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirements 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 for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lenders Name Lenders Address By my signature below, I cerFrfy to;each of the following: I am the properly 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-idenfified property for inspection purposes. Signatur�f Property Owner or Authorized AgentPropErty Owner or Authorized Agent Date �w, .�I�w,�--�1,�I -1,�� -iJ0(l V COUNTY OF LOS ANGELES` + TEMPLE CITY $ 0508 DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ON FILE ASSESSOR INF 5385-001-018 OWNER: TEL. N0: TAI, FIONA (626) 283-1932- 1842 S CALIFORNIA ST SAN GABRIEL CA 91776 APPLICANT: TEL. NO: SAME AS OWNER - CONTRACTOR: TEL. N0: SAME AS OWNER - LIC. NO ARCHITECT OR ENGINEER: TEL. NO: SUN, STEVE (626) 262-9668- 4028 ROSEMEAD BLVD. #35 LIC. NO: PICO RIVERA CA 90660 NONE PERMIT EXPIRES 180 DAYS I£ 1) WORK DOES NOT COhIMENCE, OR 2) WORK IS SDSPENDED OR ABANDONED, OR 3) FAILS TO OBTAIN CODE REQUIRED INSPECTION FEE DESCRIPTION: QDANTITY: IIOM �;f f ]9S'u1YrFXY1/;r7LN�i3�U. F1 120V, 15/20A BR CKTS 8.00 BR G1 OUTLETS-LGT,SW,RECP 24.00000 OUT G2 LIGHTING FIXTURES 12.00000 LGT HA FAU LESS 3HP 1.00 FAD H2 RES GRBG DISP LT 3HP 1.00 DIS H3 RES DISHWASHR LT 3HP 1.00 DIS H4 RES RANGE HIS LT 3HP 1.00 H00 H7 RES EXHAUST FANS 1.00 EX JB UNITS +3-10HP 1.00 AC LBAC 200 AMP PANELS, MCC 1.00 PAN TOTAL FEES ID: DPR265 ROUTE T0: 850508 ELECTRICAL PERMIT EL 0508 1604270020 6229 OAK AV AMOUNT:I TEMP CA 917801656 NEAREST CROSS STREET: 34.40 THOMAS PAGE: 596 GRID: C2 LOCALITY: TEMPLE CITY 2.80 60.00 JISSUED ON: PROCESSED BY: PLAN BY: 30.00 104/27/16 SR 13.30 13.30 FINAL DA FINAL CODE: 3.30 13.30 1 1 �O 7, 13.30 DESCRIPTION OF WORK " 24.80 18 BRANCH CIRCUITS, 24 OUTLETS, 12 LIGHT FIXTURES, FAU/AC 48.40 JUNITS, GARBAGE DISPOSAL, DISHWASHER, RANGE HOOD, EXHAUST 436.90 IFAN AND UPGRADE SERVICE PANEL TO 200 AMP PLASTIC Y/N METAL Y/N UTILITY COMPANY NOTIFI! DATE 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 (_) 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.). U 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 Contractor pursuant to the Contractors' State License Law). (,; 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 1 must have resided for at least one year prior�to completiory 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: hfti3i/Avww.leginfo.ca.gov/calaw.htmi. 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 WAI'(IJING: FAILURE TO SECURE WORKERS' COMPENSATION 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 3760 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: Cartier 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 tothe workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions Sign re of Applicant Date V 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 et 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 (Prot Name) Applicant Signature Company Name Date .JOB ADDRESS - - LOCALITY HAZARDOUS MATERIAL DECLARATION WiII the applicant or future building occupant handle a hazardous material or a mbdure containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Yes ❑ N o ❑ 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 ❑ No ❑ / i I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirements 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 for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lenders Name Lender's Address By my signature below, I cert fy toeach of the follow ng: 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. Signature Property Owner or ,Authorized Agent COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT 4L ID: ON FILE (ASSESSOR INFORMATION NUMBER: TEL. N0: 15385-001-018 (626) 262-9668- TENANT: LIC. NO: OWNER: TEL. N0: TAI, FIONA (626) 283-1932- 11842 S CALIFORNIA ST SAN GABRIEL CA 91776 1 6229 OAK AV APPLICANT: TEL. N0: SAME AS OWNER - CONTRACTOR: TEL. NO: SAME AS OWNER - LIC. NO (ARCHITECT OR ENGINEER: TEL. N0: 5UN1 STEVE (626) 262-9668- 14028 ROS34EAD BLVD. #35 LIC. NO: PICO RIVERA CA 90660 NONE PERMIT E%PIRES 180 DAYS IF 1) WORK DOES NOT COMINENCE, OR 2) WORK IE SUSPENDED OR ABANDONED, OR 3) FAILS TO OBTAIN CODE REQUIRED INSPECTION TEIdPIE CITY # 0508 ELECTRICAL PERMIT 9701 LAS TUNAS EL 0508 1604270022 TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: REPORT ID: DPR265 ROUTE TO: H50508 k'1rvAL UA'1't k"I AL CODE: S�Z� IDES CRI PT�N % AO(R!8 12 BRANCH CIRCUITS, 5 OUTLETS AND 3 LIGHT FIXTURES FOR NEW (DETACHED GARAGE Invuvn w.vu ui. I I ROUGH WIRING I I So PLASTIC Y/N METAL YIN kttt rHlu � EU1LUlrvli AUUHEBS: 1 6229 OAK AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917801656 I NEAREST CROSS STREET: Al PERMIT ISSUANCE FEE 34.40 THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY F1 120V, 15/20A BR CKTS 2.00 BR 43.20 G1 5.00000 OUT 12.50 (ISSUED ON: PROCESSED BY: PLAN BY: G2OUTLETS-LGT,SW,RECP LIGHTING FIXTURES 3.00000 LGT 7.50 104/27/16 SR TOTAL FEES 97.60 1 REPORT ID: DPR265 ROUTE TO: H50508 k'1rvAL UA'1't k"I AL CODE: S�Z� IDES CRI PT�N % AO(R!8 12 BRANCH CIRCUITS, 5 OUTLETS AND 3 LIGHT FIXTURES FOR NEW (DETACHED GARAGE Invuvn w.vu ui. I I ROUGH WIRING I I So PLASTIC Y/N METAL YIN 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 (_) 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 properly 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 Contractor pursuant Ito the Contractors' State License Law). U:I am exeml4t 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 priori to completion] of the improvements covered by this permit, I 'nnot 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.ca.gov/calaw.htmi. 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 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 sissued. 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: Cartier Policy Number Expiration Date Name of Agent Phone Number I certify that, in the performance of the work for which th is 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 11 /AAS ll� � Z ��I U Signhtture oil 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 all persons acting on behalf of myself complied and will continue to comply therewith through the application process. Applicant (Pri nt Name) Applicant Signature Company Name Date JOB ADDRESS - - - LOCALITY HAZARDOUS MATERIAL DECLARATION Will 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? WiII 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 ❑ N.o ❑ 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 Lenders Address By my signature below, I certify to!each of the following: 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. 1 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. of Signature Prgperty Owner or Authori zed Agent