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D E P A R T M E N T O F P U B L I C W O R K S
B G 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
L E G A L I U :
T R : 1 1 9 9 3 I T : 1
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T E N A N T :
O W N E R : T E L . N O :
L I N , M I A O L I N ( 6 2 6 ) 7 9 9 - 8 8 1 8 -
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C O N T R A C T O R :
T E L . N O :
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( 9 0 9 ) 3 1 9 - 7 7 7 8 -
1 1 7 0 7 8 C O L I M A R O A D
L I G N O
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A P ? / G O N D : S T A T C L A S S :
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I - - - _ _
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T E M P L E C I T Y
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G A R A G E :
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U S E Z O N E : R - 1
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B L D G S . N O W O N L O T :
V A L U A T I O N :
5 2 3 , 0 8 0
F E E S
P A I D
F E E D E S C R I P T I O N :
Q U A N T I T Y :
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B 1 P L A N C H E C K W / E N E R G Y
5 2 3 0 8 0 . 0 0
V A L
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N E W R E S I D E N T I A L
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S G A B C A 9 1 7 7 5 2 0 1 0
N E A R E S T C R O S S S T R E E T : O A K
T H O M A S P A G E : 5 9 6 G R I D : S 1 L O C A L I T Y : T E M P L E C I T Y C
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I S T L E V E L F L O O R S H E A T H
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F I R E D E P T . F R A M E I N S P E C T
B L D G D E P T . F R A M E I N S P E C T
S H E A R P A N E L S
I N S U L A T I O N / W E A T H E R S T R 1 1
I N T E R I O R L A T H / D R Y W A L L
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E X T E R I O R L A T H
L O T D R A I N A G E
S M O K E D E T E C T I O N D E V I C E S
F I R E D E P A R T M E N T A P P R O V A L
C r y
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
items) (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 property, or my employees with wages as
their sole compensation, will do (J) 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 1, 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 ContrhTtor pursuanLto the Contractors' State License
Law).
(_) I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below 1 acknowledge, that, except for my
personal residence in which I must have resided for at least
one year priorlto completion of the improvements covered by
this permit. I cannot legally sell a structure that I have built asan
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.aovicalaw.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. C� t
License Class
��� license No. / �i
Date%/r////� L Contractor Signature
WORKERS' COMPENSATION DECLARATION
WARNING: 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
irr�urance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
work; c mpe on nsurance carder and policy number are:
aftierPolicy Number Expiration
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
. l Applicant ate tI
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 ❑ No ❑
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 conceming 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
Lender's 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.
Sig f.4.,,.,, �, AeHae4zed—Agent
Date
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