HomeMy Public PortalAbout5102 Doreen Ave_Building_3/16/2015_COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
BK: 30 PG: 46 PC: 2
ASSESSOR INFORMATION NUMBER:
8585-022-047
KATHY
LOMA AVE
917803438
TEL. NO:
(626) 285 -8915 -
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 265-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
STRUCTURE: V-8
EXIST BLDG USE: RESID USE ZONE: R-1
EXIST OCC GRP:
BLDGS. NOW ON LOT: VALUATION:
25,000
FEES PAID
DESCRIPTION: QUANTITY: UOM
.SCANT:
TEL.
NO:
ABDO, RAMON
(626) 570-4473-
IAA BLDG PERMIT ISSUANCE
N. CORDOVA ST.
JAB STATE GREEN BLDG FEE
25000.00
VAL
MBRA CA 91801
JAC STRONG MOTION RESID
25000.00
VAL
JB1 PLANCHECK W/ENERGY
25000.00
VAL
JB2 PERMIT W/ENERGY
25000.00
VAL
'RACTOR:
TEL.
_
NO:
IFR INV WORK W/O PERMIT
344.00
DOL
ABDO ALFREDO DIAZ
(213)
819-5237-
TOTAL FEES
N. ARDMORE AVENUE
LIC. NO
ANGELES CA 90004
954891
OR ENGINEER:
TEL. NO:
LIC. NO:
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:(
3 00
NO. OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO '
27.80
1.00
2.50
438.10
515.50
344.00
1,328.90
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1503160042
BUILDING ADDRESS:
5102 DOREEN AV
TEMP CA 917803438
NEAREST CROSS STREET:
THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY
ISSUED ON; PROCESSED BY:
03/16/15 SR
FINA/L I�D/ATE\/ FINAL BY: CODE:
➢LSCRI PTION OF WORK
REMODEL KITCHEN, 2 BATHROOMS, REPLACE 8 WINDOWS, SLIDING
DOOR, REPLACE ENTRY DOOR, REPLACE CEILING JOISTS IN GARAGE
WITH 21X8' AS PER CODE AND INSTALL DRYWALL IN GARAGE
(SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
i
UNDERFLOOR INSULATION
FLOOR SHEATHING
ROOF SHEATHING
SHEAR PANELS
FRAME INSPECTIC7'
FIRE SPRINKLER NANGER➢
INSULATION/WEATHER STRIPI
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
�T-BAR CEILINGS
+ ADDITIONAL DATA ON FILE
LOT DRAINAGE
EE PORT ID: DPR261 ROUTE T0: BS 0508
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).):
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 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 exemlit 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 c 'nnot 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.aov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
I hereby affirm under penalty of perjury that 1 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. GS-ici
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
Code, 1 shall forthwith com ly with those provisions
S
151gnature of Ap?16ant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that 1, 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
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 ❑ 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 �20'
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, 1 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.
Signatqrj�01?poe44er or Authorized Agent
��G
Date ?/i S
' COUNTY OF IAS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
BK: 30 PG: 46 PC: 2
ASSESSOR INFORMATION NUMBER:
8585-022-047
OVNOA Yf
OWNER:
WANG, KATHY
6227 LOMA AVE
TEMP 917803438
SALLARDO, RAMON
122 N. CORDOVA ST.
ALHAMBRA CA 91801
LEONARDO ALFREDO DIAZ
130 N. ARDMORE AVENUE
IAS ANGELES CA 90004
OR ENGINEER:
TEL. NO:
(626) 285-8915-
TEL. NO:
(626) 570 -4473 -
TEL. NO:
(213) 819 -5237 -
LIC NO
954891
TEL. NO:
LIC. NO:
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
0 NO 21
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO
TEMPLE CITY
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EX
NO. OF CONS
SQ. FT STORIES TYPE
STRUCTURE: 344 1 V -B
GARAGE:
OTHER:
EXIST BLDG USE:
EXIST OCC GRP:
IBLDGS. NOW ON IAT:
# 0508 BUILDING PERMIT
RESIDENTIAL ADD
BL 0508 1503160043
T:
T NEW BUILDING ADDRESS:
OCCUP GROUPI 5102 DOREEN AV
U I TEMP CA 917803438
NEAREST CROSS STREET:
THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY
USE ZONE: TISSUED ON: PROCESSED BY:
103/16/15 SR
(
VALUATION: FINAL DA� FINjkL BY: CODE:
10,000 `
FEES PAID
FEE DESCRIPTION: QUANTITY: UOM
AA BLDG PERMIT ISSUANCE
AS STATE GREEN BLDG FEE
10000.00
VAL
AC STRONG MOTION REBID
10000.00
VAL
D1 PLANCHECK W/O EN -HC
10000.00
VAI,
D2 PERMIT W/O EN -HC
10000.00
VAL
TOTAL FEES
REPORT ID: DPR261 ROUTE TO: BS0508
DESCRi PTION OF WORK
INEW DETACHED 26.5 X 13' COVERED PATIO 344 SF.
AMOUNT:(
27.80
1.00 ISPECIAL CONDITIONS:
1.00
184.10
216.60
430.50 APPRO /V) DATE INSPECTOR SIGNATURE
VACATION AND SETBACKS
(SOILS ENGINEER APPROVAL � I
(FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR I
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
IST LEVEL FLOOR SHEATH
26 LEVEL FLOOR SHEATH I
ROOF SHEATHING
FIRE DEPT. FRAME INSPECT
BLDG DEPT. FRAME INSPECT
SHEAR PANELS
INSULATION/WEATHER STRIP(
INTERIOR LATH/DRYWALL
EXTERIOR LATH 'T
LOT DRAINAGE !�
SMOKE DETECTION DEVICES J
FIRE DEPARTMENT APPROVAL(
� II
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).):
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.).
(_) 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 exemlit 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 whicl1 I must have resided for at least
one year prior) to completion of the improvements covered by
this permit, I c 'snot 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:l/www.leainfo.ca.00v/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 Class License No. 6i 5
Date ? /S 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
Code, I shall rthwith com ly with those provisions
,L�� S
'sI ignature of Appli nt 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 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 ❑ 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
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 roperty Owner or Authorized Agent
Date
ARCHITECT OR ENGINEER:
TEL. NO:
LIC. NO:
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
NO. OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
QUALITY: 1000 FEET MATERIALS
NO NO NO
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1410200069
BUILDING ADDRESS:
5102 DOREEN AV
TEMP CA 917803438
COUNTY OF LOS
ANGELES
TEMPLE CITY #
0508
C4 LOCALITY: TEMPLE CITY
DEPARTMENT OF
PUBLIC WORKS
9701 LAS TUNAS
)FII[[jjIINAL DATE i� FINA�BY:
�DESCR TZOOl(N„ OF WORK /�`^loy/
BUILDING AND SAFETY
/ LAND DEVELOPMENT
TEMPLE CITY CA 91780
ICOMPOSITION ROOF SHINGLES
PHONE: (626) 285-0488 EXT:
LEGAL ID:
NO. OF CONST
BK: 30 PG: 46 PC: 2
SQ. FT STORIES TYPE
STRUCTURE: 2400 V -B
ASSESSOR INFORMATION NUMBER:
8585-022-047
TENANT:
EXIST BLDG USE: RESID USE ZONE: R-1
EXIST OCC GRP:
OWNER:
TEL. NO:
BLDGS. NOW ON LOT: VALUATION:
KATHY
(626) 602-4887-
1
8,300
5102 DOREEN AV
TEMP 917803438
( FEES PAID
FEE DESCRZPTION: QUANTITY: UOM:
AMOUNT:
APPLICANT:
TEL. NO:
BARK, YONG K
(626) 455-3566-
JAA BLDG PERMIT ISSUANCE
27.80
3806 RIVERSIDE DR
JAB STATE GREEN BLDG FEE 8300.00 VAL
1.00
CHINO CA 91710
JAC STRONG MOTION REBID 8300.00 VAL
0.80
ID2 PERMIT W/O EN -HC 8300.00 VAL
199.80
TOTAL FEES
229.40
CONTRACTOR:
TEL. NO:
PARK'S ROOFING
(909) 455-3566-
3806 RIVERSIDE DR.
LIC. NO
CHINO, CA 91710
960999
ARCHITECT OR ENGINEER:
TEL. NO:
LIC. NO:
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
NO. OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
QUALITY: 1000 FEET MATERIALS
NO NO NO
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1410200069
BUILDING ADDRESS:
5102 DOREEN AV
TEMP CA 917803438
NEAREST CROSS STREET:
THOMAS PAGE: 597 GRID:
C4 LOCALITY: TEMPLE CITY
ISSUED ON: PROCESSED BY:
130/20/14 SR
)FII[[jjIINAL DATE i� FINA�BY:
�DESCR TZOOl(N„ OF WORK /�`^loy/
CODE:
TEAR OFF EXISTING WOOD SHAKES,
INSTALL OSB BOARD AND 30 YR
ICOMPOSITION ROOF SHINGLES
SPECIAL CONDITIONS:
DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS
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 STRIP
(INTERIOR LATH/DRYWALL
E%TERIOR LATH
(RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
�T-BAR CEILINGS
• ADDITIONAL DATA ON FILE
(IAT DRAINAGE
REPORT ID: DPR261 ROUTE T0: SS0508
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) 1 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 Contractor pursuant .to the Contractors' State License
Law).
(_) I am exemiJt 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 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: htto://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 Class C; License No.
/Datel� Contractor Signature �✓`L
WORKERS' COMPENSATION DEC RATION
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' `nu/mb/eIr are:
�i7A-9T- '/„will) �fb/'"V 3
Cam r 1 cy umber (Expiration Date
Na eofAgent u
one 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
� ,� LO /L 1,
Signature of pplicant jG 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 ❑ 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 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.
Signature of Property Owner or Authorized Agent
Xate 4 J1- i4/