HomeMy Public PortalAbout6022 CLOVERLY AVE_Building_10/6/2011_" C L I 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
L I D :
6 5 6 1 L T : 3 0 4 O N : . 0 0 3
S S O R I N F O R M A T I O N N U M B E R :
- 0 0 7 - 0 1 7
T E L . N O :
I K , A N N ( 6 2 6 ) 2 2 1 - 0 8 7 6 -
C L O V E R L Y A V
9 1 7 8 0 2 0 2 5
i T : T E L . N O :
C R A F T H O M E I M P R O V E M E N T ( 6 2 6 ) 3 3 8 - 2 2 0 0 -
C O N T R A C T O R : T E L . N O :
Q U A L I T Y C R A F T H O M E I M P R O V E M E N T ( 6 2 6 ) 3 3 8 - 2 2 0 0 -
9 9 2 5 C O M M E R C E A V E N U E L I C . N O
T U J U N G A C A 9 1 0 4 2 5 9 6 8 4 9 .
O R E N G I N E E R : T E L . N O :
L I C . N O :
M A P N O : S E W E R M A P B O O K : P A G E : F I R E Z O N E : C M P :
1 5 O H 2 6 5 3 0 0 1
N O . O F F A M I L I E S : D W E L L I N G U N I T S : A P T / C O N D : S T A T C L A S S :
0 N O 2 1
S C H O O L W I T H I N H A Z A R D O U S
A I R Q U A L I T Y : 1 0 0 0 F E E T M A T E R I A L S
N O N O N O
T E M P L E C I T Y # 0 5 0 8 B U I L D I N G P E R M I T
9 7 0 1 L A S T U N A S A E Y E R A T I O N / R E P A I R
T E M P L E C I T Y C A 9 1 7 8 0 B L 0 5 0 8 1 1 1 0 0 6 0 0 6 3
P H O N E : ( 6 2 6 ) 2 8 5 - 0 4 8 8 E X T :
N O . O F C O N S T B U I L D I N G A D D R E S S :
S Q . F T S T O R I E S T Y P E 6 0 2 2 C L O V E R L Y A V
S T R U C T U R E : V - B T E M P C A 9 1 7 8 0 2 0 2 5
N E A R E S T C R O S S S T R E E T : W O O D R U F F
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 , C
E X I S T B L D G U S E : R E B I D U S E Z O N E : R - 1 I S S U E D O N : P R O C E S S E D B Y :
E X I S T O C C G R P : 1 1 0 / 0 6 / 1 1 S R
I
S L U G S . N O W O N I A T : V A L U A T I O N : I E
F L �� Y : C O D E :
4 , 5 0 0 i
F E E S P A I D 1 < I T I O F W O R K
R E P L A C E 1 4 W I N D O W S F R O N T H O U S E
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 : A M O U N T : I
A A B L D G P E R M I T I S S U A N C E 2 7 . 8 0
A B S T A T E G R E E N B L D G F E E 4 5 0 0 . 0 0 V A L 1 . 0 0 I S P E C I A L C O N D I T I O N S :
A C S T R O N G M O T I O N R E S I D 4 5 0 0 . 0 0 V A L 0 . 5 0
D 2 P E R M I T W / O E N - H C 4 5 0 0 . 0 0 V A L 1 3 2 . 8 0
T O T A L F E E S 1 6 2 . 1 0
A P P R O V A L S D A T E I N S P E C T O R S I G N A T U R E
s
" A D D I T I O N A L D A T A O N F I L E
L O C A T I O N A N D S E T B A C K S
S O I L S E N G I N E E R A P P R O V A L
F O U N D A T I O N / T R E N C H F O R M S
S L A B / U N D E R F L O O R
R A I S E D F L O O R F R A M I N G 1
U N D E R F L O O R I N S U L A T I O N
F L O O R S H E A T H I N G
R O O F S H E A T H I N G
S H E A R P A N E L S
F R A M E I N S P E C T I O N
F I R E S P R I N K L E R H A N G E R S
I N S U L A T I O N / W E A T H E R S T R I P I
I N T E R I O R L A T H / D R Y W A L L
E X T E R I O R L A T H
R A T E D F L O O R / C E I L A S S E M .
R A T E D W A L L A S S E M B L I E S
R A T E D S H A F T S / O P E N I N G S 1
T - B A R C E I L I N G S
L O T D R A I N A G E
I R E P O R T I D : D P R 2 6 1 R O U T E T O : 9 S O 5 0 8 I I I ' I
. . .
f a T ��
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).):
Ul, as owner of the properly, or my employees with wages as
their sole compensation, will do L) 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.).
(, 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 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 I must have resided for at least
one year prior 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: !ltp!Avww.legkfo ca.00vkalaw.hlml_
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.
711icense Class /? License No. _ G J"� Q
/late D n 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
i surance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
ptprIerf s'rcomp�n�io insurance c�6cyFile
nerr arg:
Car1�J Policy Number xpiration 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' compe ation provisions of Section 3700 of the Labor
Code, I bei ort it with thole provisions
_Z` ee
Signature of App ican� Date
JOBADDRESS
L
LOCCALITYITY
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 ❑ No ❑
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 SCAQMD or EPA
0 I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
1 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.
LOBBYIST ORDINANCE CERTIFICATION I have read this application and the information I have
Complete this section for permits
ided is Correct.
Unincorporated Los Angeles County only prov
This is to certify that I, as permit applicant, am familiar with the I agree to comply with all applicable city and county
requirements of Los Angeles County Code Chapter 2.160 at seq., ordinances and state laws relating to building
(relating to the Los Angeles County Lobbyist Ordina fiat construction.
all persons acting on behalf of myself complie d will contir ire I authorize representatives of this county to enter the
to comply therewith through the application cess. above -identified property for inspection purposes.
X Signature of Pro u h> d Agent
/_App/lip��a)r�t (Print Nate) „ _ !Applicant Signatu
Company Name ` Dat
COUNTY OF LOS ANGELES
TEMPLE CITY
W 0508
BUILDING PERMIT
DEPARTMENT OF
PUBLIC WORKS
9701 LAS TUNAS
ALTERATION/REPAIR
BUILDING AND SAFETY
/ LAND DEVELOPMENT
TEMPLE CITY CA 91780
BL 0508 1110060064
PHONE: (626) 285-0488 EXT:
LEGAL ID:
NO.
OF CONST
BUILDING ADDRESS:
ITR: 6561 LT: 304
ON: .003
SQ. FT STORIES TYPE
6022 CLOVERLY AV
STRUCTURE:
V -B
TEMP CA 917802025
(ASSESSOR INFORMATION NUMBER:
NEAREST CROSS STREET: WOODRUFF
15385-007-017
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, C
TENANT:
EXIST BLDG USE: RESID
USE ZONE: R-1
ISSUED ON: PROCESSED BY:
EXIST OCC GRP:
10/06/11 SR
OWNER:
TEL. NO:
SLOGS. NOW ON LOT:
VALUATION:
FINAL DATE FI[il�. BY: CODE:
WOMAC K, ANN
(626) 221-0876-
1,800
1�1/��/''^\,�'}I/f0[1
6022 CIOVERLY AV
I
TEMP 917802025
FEES PAID
E'S, R►Z!P/
C b OF WORK
REPLACE 6 WINDOWS ON GUEST BE
FEE DESCRIPTION:
QUANTITY: DOM: AMOUNT:
APPLICANT:
TEL. NO:
QUALITY CRAFT HOME IMPROVEMENT
(626) 338-2200-
AA BLDG PERMIT ISSUANCE
27.80
AB STATE GREEN BLDG FEE
1800.00 VAL 1.00
SPECIAL CONDITIONS:
AC STRONG NATION REBID
1800.00 VAL, 0.50
D2 PERMIT W/O EN -HC
1800.00 VAL 82.20
TOTAL FEES 111.50
CONTRACTOR:
TEL. NO:
APPROVALS DATE INSPECTOR SIGNATURE
QUALITY CRAFT HOME IMPROVEMENT
(626) 338-2200-
9925 COMMERCE AVENUE
LIG NO
LOCATION AND SETBACKS
TUJUNGA CA 91042
596849 '
SOILS ENGINEER APPROVAL
(ARCHITECT OR ENGINEER:
TEL. NO:
FOUNDATION/TRENCH FORMS
I
-
LIC. NO:
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMP:
UNDERFLOOR INSULATION
115OH265
3 00
I
FLOOR SHEATHING
[NO. OF FAMILIES: DWELLING UNITS:
APT/COND: STAT CLASS:
0
NO 21
ROOF SHEATHING
SCHOOL WITHIN
HAZARDOUS
SHEAR PANELS
(AIR QUALITY: 1000 FEET
MATERIALS
NO NO
NO
FRAME INSPECTION
FIAE SPRINKLER HANGERS
INSULATION/WEATHER STRIP(
INTERIOR LATH DRYWALL
EXTERIOR LATH
RATED FLOOR/CELL ASSEM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T -BAR CEILINGS
' ADDITIONAL DATA ON FILE
LOT DRAINAGE
REPORT ID: DPR261
ROUTE TO: SS0508
-�
406.
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION JOB ADDRESS
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.).
(_) 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 I must have resided for at least
one year prior 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: http:/Mw_w-L-Qinfo_ca..covtcalaw_htrn!_
Date:
Signature of Property Owner or Authorized Agent
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 No.w
Date /f1��� Contractor Signature
l
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.
1 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
work rs' omp ati ins an a carrier and olt�ic�t 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 f I should become subject to the
workers' com a ion pr isions o ion 3700 of a bor
;Code, 1 s ort ase provision
gna ure 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 et seq.,
(relating to the Los Angeles County Lobbyist Ordin d that
all persons acting on behalf of myself compli nd wi ontinue
to comply therewith through the applicatio roces
, PIP-/ cam'
Ap icant (Printgame) Applicant SignaturV
Company Nam Date or
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 ❑ No ❑
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
El Notification letter sent to SCAQMD or EPA
I] 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.
Signature rope razed Agent
7
Date lD�
l
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
J. ID:
6561 IT: 304
ISSOR INFORMATION NUMBER:
-007-017
I OMER;
IWOMACK, ANN
16022 CLOVERLY AV
(TEMP 917802025
I
(APPLICANT:
ISAME AS OWNER
CONTRACTOR:
SAME AS OWNER
ARCHITECT OR ENGINEER:
ON: .003
TEL. NO:
(626) 221 -0876 -
TEL. NO:
TEL. NO:
LIC. NO
TEL, NO:
LIC. NO:
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:(
15OH265 3 001
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1
0 NO 21
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
STRUCTURE: V -B
XIST BLDG USE: REBID
XIST OCC GRP:
LOGS. NOW ON IAT:
FEE DESCRIPTION
AA BLDG PERMIT ISSUANCE
AS STATE GREEN BLDG FEE
AC STRONG MOTION RESID
B2 PERMIT W/ENERGY
DPR261
USE ZONE: R-1
VALUATION:
8,000
FEES PAID
QUANTITY: DOM: AMOUNT:
ROOTS TOP BS0508
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1111030062
BUILDING ADDRESS:
6022 CLOVERLY AV
1 TEMP CA 917802025
NEAREST CROSS STREET: WOODRUFF
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, C
ISSUED ON: PROCESSED BY:
11/03/11 SR
(FINAL DATE(/T/y, FI AL BY: CODE:
Iit�OF WORK
(KITCHEN REMODEL IN EXISTING HOUSE
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS 1
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
FLOOR SHEATHING
ROOF SHEATHING
SHEAR PANELS
FRAME INSPECTION
FIRE SPRINKLER HANGERS
INSULATION/WEATHER STRIPI
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM. � 1
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T -HRR CEILINGS
LOT DRAINAGE
a
1
27.80
8000.00
VAL
1.00
8000.00
VAL
0.80
8000.00
VAT,
201.80
TOTAL FEES
231.40
ROOTS TOP BS0508
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1111030062
BUILDING ADDRESS:
6022 CLOVERLY AV
1 TEMP CA 917802025
NEAREST CROSS STREET: WOODRUFF
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, C
ISSUED ON: PROCESSED BY:
11/03/11 SR
(FINAL DATE(/T/y, FI AL BY: CODE:
Iit�OF WORK
(KITCHEN REMODEL IN EXISTING HOUSE
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS 1
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
FLOOR SHEATHING
ROOF SHEATHING
SHEAR PANELS
FRAME INSPECTION
FIRE SPRINKLER HANGERS
INSULATION/WEATHER STRIPI
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM. � 1
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T -HRR CEILINGS
LOT DRAINAGE
a
1
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).):
(JI, 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.).
(_) 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 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 I must have resided for at least
one year prior 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: f_
Date: V/3//
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
1 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 No.
Date 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
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
C , I shauforthyvttl, om I witb those provisiong
Signature of Applicant Date r
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
too comply therewith through the app ' anon proce7s.
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 (lie 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 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 SCAQMD 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.
Signature of Property/Ow er or Authorized Agent
L
Date//���/