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C O U N T Y O F L O S A N G E L E S
D E P A R T M E N T O F P U B L I C W O R K S
B U I L D I N G A N D S A F E T Y / L A N D D E V E L O P M E N T
i . E G A L I V :
T R : 6 5 6 1 L T : 7 2 9 B L : . 0 0 1
A S S E S S O R I N F O R M A T I O N N U M B E R :
8 5 8 7 - 0 0 5 - 0 0 3
T E N A N T :
O W N E R :
G O O D I N G K E N N E T H B & S H A R O N R
5 7 0 9 O A K A V
T E M P 9 1 7 8 0 2 4 3 1
A P P L I C A N T :
F R A N K M A R R O N E & S O N S
9 8 6 0 L O W E R A Z U S A
E L M O N T E 9 1 7 3 1
C O N T R A C T O R :
F R A N K M A R R O N E A N D S O N S
9 8 6 0 L O W E R A Z U S A R D .
E L M O N T E , C A 9 1 7 3 1
A R C H I T E C T O R E N G I N E E R :
R J A D E S I G N
1 1 4 4 N . E D E N F I E L D A V E .
C O V I N A , C A 9 1 7 2 2
S E W E R M A P B O O K : P A G E :
T E L . N O :
( 6 2 6 ) 2 8 7 - 7 4 2 9 -
T E L . N O :
( 6 2 6 ) 4 4 4 - 2 5 4 8 -
T E M P L E C I T Y # 0 5 0 8
9 7 0 1 L A S T U N A S
T E M P L E C I T Y C A 9 1 7 8 0
P H O N E : ( 6 2 6 ) 2 8 5 - 0 4 8 8 E X T :
S E W E R / S E P T I C : X
E X I S T O C C G R P :
B L D G S . N O W O N L O T :
C O N N E C T I O N T Y P E :
O R I G I N A T I O N :
L E N G T H M L T O P L : S T A T I O N : D E P T H :
M A N H O L E R E F E R E N C E : U P P E R / L O W E R :
C O U N T Y I M P R O V E M E N T N U M B E R :
P L A N C H E C K N U M B E R : . . .
J O B N U M B E R :
T R U N K P E R M I T N U M B E R : r ' .
R O A D P E R M I T N U M B E R :
A F F A D A V I T : N O
W A I V E R : N O
E A S E M E N T : N O
R E C O R D I N S T R U M E N T N B R : R E C O R D D A T E :
H I G H W A Y / S T R E E T W I D E N I N G :
S T A T E E N C R O A C H M E N T P E R M I T N U M B E R :
T E L . N O : F E E S P A I D
( 6 2 6 ) 4 4 4 - 2 5 4 3 -
L I C . N O F E E D E S C R I P T I O N : Q U A N T I T Y : U O M :
3 9 7 8 8 4 C 3 6
0 1 P E R M I T I S S U A N C E F E E
_ 1 9 C O N N A D D T N L B L D G ( S ) 1 . 0 0 E A C
T E L . N O : T O T A L F E E S
( 6 2 6 ) 7 0 5 - 7 0 1 9 -
L I C . N O :
N O N E
R E P O R T I D : D P R 2 6 6
R O U T E T O ; S S 0 5 0 8
S E W E R P E R M I T
S E 0 5 0 8 0 3 0 8 2 2 0 0 0 3
B U I L D I N G A D D R E S S :
5 7 0 9 O A K A V
T E M P C A 9 1 7 8 0 2 4 3 1
N E A R E S T C R O S S S T R E E T : L I V E O A K
T H O M A S P A G E : 5 9 6 G R I D : J 3 L O C A L I T Y : T E M P L E C I T Y
I S S U E D O N : P R O C E S S E D B Y : E X P I R E S O N :
0 8 / 2 2 / 0 3 J K 0 2 / 1 8 / 0 4
F I N A L D A T E F I S A b , B Y : C O D E :
D k R I P T I O O N N O F W O R K
C O N N E C T G A R A G E W I T H W O R K S H O P , S T O R A G E A N D B A T H R O O M T O S E W E R
L I N E
S P E C I A L C O N D I T I O N S :
A P P R O V A L S
A M O U N T : N E W H O U S E S E W E R
2 7 . 7 5 C O N N E C T A D D I T I O N A L
3 0 . 4 5 B U I L D I N G O R W O R K
5 8 . 2 0
S E P T I C T A N K , S E E P A G E P I T
A N D / O R D R A I N F I E L D
D R Y W E L L
A L T E R , R E P A I R , S E W E R O R
S E W A G E D I S P O S A L S Y S T E M
D I S C O N N E C T P L U G A N D
A B A N D O N H O U S E S E W E R
B A C K F I L L S E P T I C T A N K S _
S E E P . P I T C E S S P O O L
G R A Y W A T E R S Y S T E M
D A T E I N S P E C T O R S I G N A T U R E
b - l b o y f ��- -
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 s in full force and effect.
o Signature Date
OWNER BUILDER DECLARATION
I hereb affirm under penalty of perjury that I am exempt from the
Contractors License Law for the following reason (Sec. 7031.5, Business
and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its
issuance, also requires the applicant for such permit to file a signed
statement that he or she is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of
Division 3 ofthe Business and Professions Code) or that he or she is
exempt therelrom and the basis for the alleged exemption. Any violation
of Section 7031.5 by any applicant lora permit subjects the applicant to a
civil penalty of not more than five hundred dollars ($51
❑ I am exempt under Sec. , BA P.C. for this reason.
[ Electrical, Plumbing & Sewer Permits Only ]
❑ I, as owner of the property, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions Code:
The Contractors License Law does not apply to an owner of property who
builds or improves framed. and who does such work himself or herself,
provided "hat such improvements are not intended or offered for sale. If,
however, the building or improvements sold within one year of completion,
the owner -builder will have the burden of proving that he or she did not
build or improve for the purpose of sale ).
[ All Other Permits ]
❑ [,as owner of the property, or my employees with wages as their sole
compensation. will do the work. and the structure is not intended or offered
Lor sale (Sec 7044, Business and Professions Code The Contractors
License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himself or herself or through his or her
own employees, provided that such 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 he or she did not build or improve for the purpose of sale I
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code. The Contractors License Law does not apply to an owner of property
who builds or improves thereon, and who contracts for such projects with
a camentods) licensed pursuant to the Contractors License Law)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent 1. self -insure for
workers compensation, as provided for by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued.
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:
A 1_
Carder �_• �'� V—t.-�'1
�hcy Number���� �Y
❑ 1 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 10 the orkers compensa' n la sof California, and agree that d
I shou d bec e s Ili work is co sation provisions of
Secti 370 of a Labor e, I s all rlh h comply with those
provi ons.
pp nt nature Dat ��
WARN : FAILURE TO SECURE WORKER'S COMPENSATION
COVE A E IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER
TO C IM AL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THO D DOLLARS ($100,000), IN ADDITION TO THE COST OF
COMP SATION, DAMAGES AS PROVIDED FOR /N SECTION 3706
OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LOBBYIST ORDINANCE CERTIFICATION
j' Complete this section for permits in 7
` 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
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?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future building
accupant require a permit for construction or modification from the South
Coast Au Quality Management District (SCAOMD)? See permitting
checklist for guidelines.
Yes ❑ No ❑
I have read the hazardous materials information guide and the SCAOMD
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 Lor obtaining a permit from
the SCAOMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to SCAOMD or EPA
❑ I declare that notification of asbestos removal is not applicable to
addressed project.
CONSTRUCTION LENDING AGENCY
hereby afLrmuntler penalty of perjury that there is a construction lending
agency for the performance of the work for which this permit is issued
(Sec. 3097, Q,C.).
Lenders Name
Lenders Address
".'Q?
I certify that I have read this application and state
under the penalty of perjury that the above
information is correct. / agree to comply with all City
and County ordinances and State laws relating to
building construction, and hereby authorize
rgpresgntatiyes of this Co
anty enter uppn the
ov a Ioned pro rt fo n pecticyfj poses.
Owner Signature Date Company Name (if employetl by an enhty/agency) Data Applicanj�r Agent Sigrli ulu" VDal