HomeMy Public PortalAbout4927 Doreen Ave_Building_5/15/2014_COUNTY OF LOS ANGELES TEMPLE CITY N 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS NEW RESIDENTIAL
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1402060086
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST NEW BUILDING ADDRESS:
TR: 13645 LT: 54 SQ. FT STORIES TYPE OCCUR GROUP 4927 DOREEN AV
STRUCTURE: 3838 2 V-B R-3 I TEMP CA 917804117
ASSESSOR INFORMATION NUMBER: GARAGE: I NEAREST CROSS STREET:
8585-024-040 OTHER: 120 1 V-B U THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY
TENANT: USE ZONE: R-1 ISSUED ON: PROCESSED BY:
105/15/14 SR
OWNER: TEL. NO: SLUGS. NOW ON LOT: VALUATION: FINAL DATE FINAL BY: CODE:
HSU, RICKY (714) 767-8091- 1 523,970/
4927 DOREEN AV �(/
TEMP 917604117 FEES PAID ID�TIONY r OF WORK
1 INEW 2-STORY SFD 5 BEDROOMS, 4 BATHROOMS, 1 POWDER, 2ND FLi
IFEE DESCRIPTION: QUANTITY: DUN: AMOUNT:IDEN, COVERED PORCH AND COVERED PATIO 309 SF
APPLICANT: TEL. NO: I I
LAI, KAMEN (626) 288-2651- IBI PLANCHECK W/ENERGY 523970.00 VAL 3,821.50 I
8748 E VALLEY BLVD K IAA BLDG PERMIT ISSUANCE 27.80 ISPECIAL CONDITIONS:
ROSEMEAD CA 91770 IAB STATE GREEN BLDG FEE 523970.00 VAL 21.00 IFIRE SPRINKLERS REQUIRED
IAC STRONG MOTION REBID 523970.00 VAL 52.40 1
182 PERMIT W/ENERGY 523970.00 VAL 4,495.90 1
CONTRACTOR: TEL. NO: 108 CERTIF OF OCCUPANCY 101.40 (APPROVALS DATE INSPECTOR SIGNATURE
T AND S GROUP CONSTRUCTION (626) 757-8033- 1 TOTAL FEES 8,520.00 1
9040 STEELE STREET LIC. NO i (LOCATION AND SETBACKS 1
ROSEMEAD CA 91770 958027
I (SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. NO: (FOUNDATION/TRENCH FORMS
LEE, PETER (626) 280-9000- I V
8748 E VALLEY BLVD SUITE L LIC. NO: 1 ;SLAB/UNDER FLOOR
ROSEMEAD CA 91770 958027
* 1RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP; 1 1UNDERFLOOR INSULATION ; 1
3 011
11ST LEVEL FLOOR SHEATH
N0. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS:
1 NO O1 i � 12ND LEVEL FLOOR SHEATH )
SCHOOL WITHIN HAZARDOUS IROOF SHEATHING ZI "MAA
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO i (FIRE DEPT. FRAME INSPECTf
1BLDG DEPT. FRAME INSPECT'/�� / n
;SHEAR PANELS
I I 1 i
NSULATION/WEATHER STRIP .A� f
(INTERIOR LATH/DRYWALL
IEXTERIOR LATHY
ILOT DRAINAGE ( fill I
ISMOKE DETECTION DEVICES
I
I (FIRE DEPARTMENT APPROVAL( I
1* ADDITIONAL DATA ON FILE
IRE PORT ID: DPR261 ROUTE T0: 850508 I I
I I I
a•
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I 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).):
U 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 Contr9Ftor 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 priorl to completioqof 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: httr://www.leainfo.ca:aov/calaw.htmi.
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. }��Z
Date �� Contractor Signature
WORKERS' COMPENSATI ECLARATION
WA'R'NING: 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 1 should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code s IIWforthwitht,ply with those provisionssnot of 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
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 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
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.
Signs t a of er or Authorized Agent
Date
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
TR: 13645 IT: 54
ASSESSOR INFORMATION NUMBER:
8585-024-040
TENANT
OWNER:
TEL. NO:
HSU, RICKY
(714) 767-8091-
4927 DOREEN AV
9701 LAS TUNAS
TEMP 917804117
APPLICANT:
TEL. NO:
LAI, KAMEN
(626) 288-2651-
8748 E VALLEY BLVD K
PHONE: (626) 285-0488 EXT:
ROSEMEAD CA 91770
VAL
CONTRACTOR:
TEL. NO:
S AND S GROUP CONSTRUCTION
(626) 757-8033-
9040 STEELE STREET
LIC. NO
ROSEMEAD CA 91770
958027
ARCHITECT OR ENGINEER:
TEL. NO:
LEE, PETER
(626) 280-9000-
8748 E VALLEY BLVD SUITE L
LIC. NO:
ROSEMEAD CA 91770
958027 t
MAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMP -
3 00
NO. OF FAMILIES: DWELLING UNITS:
APT/CONDI STAT CLASS -
0
NO 12
SCHOOL WITHIN
HAZARDOUS
AIR QUALITY: 1000 FEET
MATERIALS
NO NO
NO
FEES PAID
FEE DESCRIPTION: QUANTITY: DOM
D1 PLANCHECK W/O EN -HC
TEMPLE CITY
# 0508
AA BLDG PERMIT ISSUANCE
9701 LAS TUNAS
AB STATE GREEN BLDG FEE
TEMPLE CITY CA 91780
VAL
AC STRONG MOTION RESID
PHONE: (626) 285-0488 EXT:
VAL
NO. OF
CONST
NEW
VAL
SQ. FT STORIES
TYPE
OCCUP GROUP
(STRUCTURE:
0 0
V -B
R-3
GARAGE:
651 1
V -B
U
OTHER:
USE ZONE: R-1
SLIDE. NOW ON LOT:
VALUATION:
29,959
FEES PAID
FEE DESCRIPTION: QUANTITY: DOM
D1 PLANCHECK W/O EN -HC
29959.00
VAL
AA BLDG PERMIT ISSUANCE
AB STATE GREEN BLDG FEE
29959.00
VAL
AC STRONG MOTION RESID
29959.00
VAL
D2 PERMIT W/O EN -HC
29959.00
VAL
TOTAL FEES
- ADDITIONAL DATA ON FILE
REPORT ID: DPR261 ROUTE TO: ES0508
BUILDING PERMIT
NEW RESIDENTIAL
BL 0508 1402060087
BUILDING ADDRESS:
4927 DOREEN AV
TEMP CA 917804117
NEAREST CROSS STREET:
THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY
ISSUED ON: PROCESSED BY:
05/15/14 SR
FINAL DATE FINAL BY: CODE -
DEC
ODE:
DEJ\SCCy�RIPC�TAI�ION OF WORK '/�Y.�
DETACHED 3 -CAR GARAGE
AMOUNT:
456.50
27.80 SPECIAL CONDITIONS:
2.00
3.00
537.00
1.026.30 1APPROVALS
.ON AND SETBACKS
ENGINEER APPROVAL
.TION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
IST LEVEL FLOOR SHEATH
2ND LEVEL FLOOR SHEATH
DATE INSPECTOR SIGNATURE
ROOF SHEATHING
FIRE DEPT. FRAME INSPECT('\
BLDG DEPT. FRAME INSPECT
V
SHEAR PANELS
INSULATION/WEATHER STRIP
INTERIOR LATH/DRYWALL- C
EXTERIOR LATH _
DETECTION DEVICES
i I
DEPARTMENT APPROVAL(
I
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOBIDDRESS
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 I, as owner of the property, or my employees with wages as
their sole compensation, will do (-/)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 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 ContrbTtor pursuant.to the Contractors' State License
Law).
U 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 priorito completior) 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.lecinfo.ca:cov/calaw.html.
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 CI ss License No. �� Z
Date 5 contractor Signature
WORKERS' COMPENSATIO LARATION
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
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 to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' co ensation provisions of Section 3700 of the Labor
Code, I all fo with ply with those provisions
Sign dFe E 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
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 checklistfor 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
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.
Sign ure of ��,�w////rier or Authorized Agent
D e v �X1
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
JTR: 13645 IT: 54
1
ASSESSOR INFORMATION NUMBER:
18585-024-040
1
TENANT:
OWNER:
JHSU, RICKY
4927 DOREEN AV
TEMP 917804117
APPLICANT:
PAN, GUIFANG
3376 SEAMAN AVENUE
JEL MONTE CA 91733
CONTRACTOR:
JGF FIRE PROTECTION INC.
110105 RIO HONDO PKWY
JEL MONTE CA 91733
(ARCHITECT OR ENGINEER:
TEL. NO:
TEL. NO:
(626) 822 -1030 -
TEL. NO:
(626) 350 -3196 -
LIC. NO
975442
TEL. NO:
LIC. NO:
I
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
00
INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS:
NO 20
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO
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
FEE DESCRIPTION:
AA BLDG PERMIT ISSUANCE
AB STATE GREEN BLDG FEE
DO FIRE SPRINKLER PC
D2 PERMIT W/O EN -HC
REPORT ID: DPR261
I
TEMPLE CITY
# 0508
BUILDING PERMIT
FEES
9701 LAS TUNAS
FIRE SPRINKLER
IDESCRIPTION OF WORK
TEMPLE CITY
CA 91780
BL 0508 1506240090
INSTALLATION OF FIRE SPRINKLERS
PHONE: (626)
285-0488 EXT:
AMOUNT:
NUMBER OF ADDED/RELOCATED
27.80
BUILDING ADDRESS:
4000.00
SQ. FT
SPRINKLER HEADS
40
4927 DOREEN AV
STRUCTURE: 4489
98.40
TEMP CA 917804117
VAL
115.80
TOTAL FEES
NEAREST CROSS STREET:
243.00
THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY CA
EXIST
BLDG USE:
JISSUED ON: PROCESSED BY:
EXIST
OCC GRP:
106/24/15 SR
IBLDGS.
NOW ON LOT:
VALUATION:
IF AL D TE FIN BY: CODE:
FEE DESCRIPTION:
AA BLDG PERMIT ISSUANCE
AB STATE GREEN BLDG FEE
DO FIRE SPRINKLER PC
D2 PERMIT W/O EN -HC
REPORT ID: DPR261
I
ROUTE TO: BS0508
APPROVALS
FIRE DEPARTMENT INSPECT
FIRE SPRINKLER HANGERS
FIRE DEPARTMENT APPROVAL
DATE INSPECTOR SIGNATURE
4,000
VVV
FEES
PAID
IDESCRIPTION OF WORK
INSTALLATION OF FIRE SPRINKLERS
QUANTITY:
UOM:
AMOUNT:
27.80
4000.00
VAL
1.00
ISPECIAL CONDITIONS:
4000.00
VAL
98.40
4000.00
VAL
115.80
TOTAL FEES
243.00
ROUTE TO: BS0508
APPROVALS
FIRE DEPARTMENT INSPECT
FIRE SPRINKLER HANGERS
FIRE DEPARTMENT APPROVAL
DATE INSPECTOR SIGNATURE
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 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 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 Contra?tor 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 priorlto completion' of the improvements covered by
this permit, I cqnnot 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.leainfo.ca.aov/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. /�
-License Class -UL License No_9
// t �
Date01_�IviConnnrc�or Signature v
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.
1 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. 311!
� 2 b
Policy No. _I j 1! )
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 poll cyy n er are:
/O o -for
Carder 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
Code, I shall forthwith comply with those provisions p
L- �IAI I",p, SDA -may WIJ-
Signature of Applidant j 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 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
I. 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 ❑ N o ❑ %
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requiremernts
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 Property wrier or Authorized Agent
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