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Home My Public Portal About6137 CAMELLIA AVE_Plumbing_8/19/2013_W3ISAS a. AVND AND =8110N ANYdWOJ AII4IIO IS3I SVD SH34]INIHdS NMVO 53HOIXId DNIHWMd H3IV3H H3SVM IOH IN3A SVD DNIdId SVO DNI67J(I4d HDNOH N/A TYI3W N/A JIISH'Id 3JIAH35 H3IVM NHOM 3Y'IS H3ONN 3HNIVNDIS NOID3d SNI 3IV0 STVAOHddV ;SNOIIIONOJ OVIJ3d5 ONIHWN'Id DNIISIX3 OI 53DNYHJ ON HNI. NIA'IVM M3� 130V'Id3H 0 IIdIHJS3O 7 'ROOD 'Ad TYNI3 3IV0 TYNI3 HS ET/61/80 ;AS NVId ;AH 035S3JOHd :NO O3DSSI 00'46 OZ'91 VZ) AIID 34dW3I :AIITdJ04 Zf :OIHD 96S :3DVd SYWOHI 08'LZ :I33HI5SSOHD IS3HV3N bEL T 0 L1 VD dW3I INNOWY AV VITI3WYD LETS 553HOOY DNI0RID3 90006180ET SOSO ad IIWH3d DNI8WN4d 805058 :OI 3IpOH E9ZHdO :0I IHOd3H 34I3 NO VIVO TYNOIIIQOV a 5333 4VIOI RId 00'T SH3M0HS/SH[1IHIVH LO 333 3JNVOSSI IIWH3d ID :WON :AIIINVOO ;N0IIdIHJS3O 333 OIVd 5333 =IX3 88"-SBZ (9Z9) m3N0Hd 08L16 VD AIIJ 3'IdW3I SYNNS SV'I TOL6 8050 # AIIJ 34dw3 v�nidX3 ON 'DIH ON '435 :H33NION3 HO ID3IIHOHV . Z65899908b6 VJ 'ONOWHJIH ON 'JIR 3AIH0 30I53N'd'I TOEb -065E-ZLZ ( S , 650S%HOMN33H0 :ON '43I 'HOIJVNINOJ NOSH3ONY ANOI ON "I3I 'ImiliddV bCLTOBLT6 dWSM AVVI443WYJ LET9 SEZT-LEZ (9Z9) V0NI'I'sof ISHN0ZNV0 :ON "I3I :WSNM0 INVN3I EZO-SIO-58E5 ;H381^1NN NOIIVWH03NI HOSS3SSY said NO 0I TYD3'i IN3WdD43A30 0NV4 / AI33VS ONV DNIO^INH SNHOM JI'IHNd 30 INSKLHVd3O SMOMV SO4 30 AINNOD ' 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 1, 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.). 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 Contragtor 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 whicl' I must have resided for at least one year priori to completion, 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: httD://www.leoinfo.ca.00v/calaw.html. Date: 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. .a License C ass � P/ 7� License No. L)U p y 9 Date ?//'71/ Contractor Signature ✓ WORKERS' COMPENSATION DECLARATION WA41NIING: 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 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 coo ers' pens tion insurance carver and olicy nu ben e: arner o Icy 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 compl ith those provisions 0- Signature of 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 (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? 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 ❑ N o ❑ 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). 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. 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 of pryy Ow or uthorized Agent Date 7//