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Home My Public Portal About6139 Encinita Ave_Building_10/29/2014_,lam,• ��, • COUNTY OF LLQ. A.\GELS" �DEPARTMENT OF PT,,,BLIC WORw. BUILDING AND SAFETY / LAND DEVELOPMENT GAL ID: .: 5904 LT: 289 SESSOR INFORMATION NUMBER: B4-012-022 DANNY ENCINITA AVE .E CITY CA 91780 *AME AS OWNER :ONTRACTOR: TAME AS OWNER '?RCHITECT OR ENGINEER: CCA ENGINEERING INC. *232 GARVEY AVE., #206 30SEMEAD, CA 91770 TEL. NO: (626) 216 -9110 - TEL. NO: TEL. NO: LIC. NO TEL. NO: (626) 571 -4000 - LIC. NO: NONE NAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 01 YO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1 NO 01 SCHOOL WITHIN HAZARDOUS 4IR QUALITY: 1000 FEET MATERIALS NO NO NO TEMPLE CITY 9701 LAS TUNAS TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: NO. OF CONST NEW SQ. FT STORIES TYPE OCCUR GROUP STRUCTURE: 4781 1 V -B R-3 GARAGE: 428 1 V -B U OTHER: 600 1 V -B U USE ZONE: R-1 # 0508 NOW ON LOT: VALUATION: 674,400 BUILDING PERMIT NEW RESIDENTIAL BL 0508 1405130053 BUILDING ADDRESS: 6139 ENCINITA AV TEMP CA 917801637 NEAREST CROSS STREET: THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY ISSUED ON: PROCESSED BY: 10/29/14 SR FINAL DA E FINAL BY: CODE: FEES PAID IDESCRIFriON F WORK NEW 1 -STORY SFD: 4 BEDROOMS, 5 BATHROOMS WITH ATTACHED 1 FEE DESCRIPTION: QUANTITY: DOM: AMOUNT:JCAR GARAGE, PORCH AND LOGGIA 81 PLANCHECK W/ENERGY 674400.00 VAL 4,753.30 1 AA BLDG PERMIT ISSUANCE 27.80 (SPECIAL CONDITIONS: AB STATE GREEN BLDG FEE 674400.00 VAL 27.00 IFIRE SPRINKLERS REQUIRED AC STRONG MOTION RESID 674400.00 VAL 67.40 B2 PERMIT W/ENERGY 674400.00 VAL 5,592.20 08 CERTIF OF OCCUPANCY 101.40 JAPPROVALS TOTAL FEES 10,569.10 LOCATION AND SETBACKS LA�/�� _✓,Af�^4 '�WE�V�P�/'x"10 iS01LS ENGINEER APPROVAL it FOUNDATION/TRENCH FORMS It SLAB/UNDER FLOOR RAISED FLOOR FRAMING (UNDERFLOOR INSULATION 1ST LEVEL FLOOR SHEATH 2ND LEVEL FLOOR SHEATH ROOF SHEATHING i FIRE DEPT. FRAME INSPECT( BLDG DEPT. FRAME INSPECCT REPORT ID: DPR261 ROUTE TO: SS0508 INSULATION/WEATHER STRIP N INTERIOR LATH/DRYWALL } EXTERIOR LATH LOT DRAINAGE SMOKE DETECTION DEVICES FIRE DEPARTMENT APPROVAL( DATE INSPEECTOR SIGNATURE 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 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 exeml t 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://www.leoinfo.ca.cov/calaw.htmi. Date:.( O l> y/ T 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 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 Code, 1 shall forthwith comply with those provisions 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 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 JOB ADDRESS t r r 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 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. Si of Property Owner or Authorized Agent Date /-o COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT LEGAL ID: TR: 5904 LT: 289 ASSESSOR INFORMATION NUMBER: 5384-012-022 TENANT OWNER: LEE, DANNY 6139 ENCINITA AVE TEMPLE CITY CA 91780 APPLICANT: SAME AS OWNER CONTRACTOR: SAME AS OWNER ARCHITECT OR ENGINEER: TCA ENGINEERING INC. 6232 GARVEY AVE., #206 ROSEMEAD, CA 91770 TEL. NO: (626) 616 -9110 - TEMPLE CITY # 0506 BUILDING PERMIT 9701 LAS TUNAS NEW RESIDENTIAL TEMPLE CITY CA 91780 BL 0508 1405130054 PHONE: (626) 285-0488 EXT: FEE DESCRIPTION: TEL. NO: - D1 PLANCHECK W/0 EN -HC AA BLDG PERMIT ISSUANCE AS STATE GREEN BLDG FEE AC STRONG MOTION RESID D2 PERMIT W/O EN -HC TEL. NO: LIC. NO TEL. NO: (626) 571 -4000 - LIC. NO: NONE MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 00 NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 0 NO 12 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO REPORT ID: DPR261 QUANTITY: DOM: 20295.00 VAL 20295.00 VAL 20295.00 VAL 20295.00 VAL TOTAL FEES ROUTE TO: BS0508 LOCALITY: TEMPLE CITY CA CODE: AMOUNT: 341.20 27.80 ISPECIAL CONDITIONS: 1.00 2,00 401.40 773.40 APPROVALS DATE INSPECTOR SIGNATURE 1 LOCATION AND SETBACKS SOILS ENGINEER APPROVAL�� FOUNDATION/TRENCH FORMS tl SLAB/UNDER FLOOR RAISED FLOOR FRAMING UNDERFLOOR INSULATION IST LEVEL FLOOR SHEATH 2ND LEVEL FLOOR SHEATH ROOF SHEATHING FIRE DEPT. FRAME INSPECT; BLDG DEPT. FRAME INSPECT,W �^f (� /� SHEAR PANELS INSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL EXTERIOR LATH LOT DRAINAGE SMOKE DETECTION DEVICES - FIRE DEPARTMENT APPROVAL NO. OF CONST NEW BUILDING ADDRESS: SQ. FT STORIES TYPE OCCUP GROUP 6139 ENCINITA AV STRUCTURE: 0 V -B R-3 TEMP CA 917801637 GARAGE: 441 1 V -B U NEAREST CROSS STREET: OTHER: THOMAS PAGE: 596 GRID: J2 USE ZONE: R-1 ISSUED ON: PROCESSED BY: 10/29/14 SR SLOGS. NOW ON LOT: VALUATION: 20,295 FINAL D E FIN/AL�//g//y(//j� FEES PAID D SC TIOIp OF WORK DETACHED 2 CAR GARAGE FEE DESCRIPTION: TEL. NO: - D1 PLANCHECK W/0 EN -HC AA BLDG PERMIT ISSUANCE AS STATE GREEN BLDG FEE AC STRONG MOTION RESID D2 PERMIT W/O EN -HC TEL. NO: LIC. NO TEL. NO: (626) 571 -4000 - LIC. NO: NONE MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 00 NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 0 NO 12 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO REPORT ID: DPR261 QUANTITY: DOM: 20295.00 VAL 20295.00 VAL 20295.00 VAL 20295.00 VAL TOTAL FEES ROUTE TO: BS0508 LOCALITY: TEMPLE CITY CA CODE: AMOUNT: 341.20 27.80 ISPECIAL CONDITIONS: 1.00 2,00 401.40 773.40 APPROVALS DATE INSPECTOR SIGNATURE 1 LOCATION AND SETBACKS SOILS ENGINEER APPROVAL�� FOUNDATION/TRENCH FORMS tl SLAB/UNDER FLOOR RAISED FLOOR FRAMING UNDERFLOOR INSULATION IST LEVEL FLOOR SHEATH 2ND LEVEL FLOOR SHEATH ROOF SHEATHING FIRE DEPT. FRAME INSPECT; BLDG DEPT. FRAME INSPECT,W �^f (� /� SHEAR PANELS INSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL EXTERIOR LATH LOT DRAINAGE SMOKE DETECTION DEVICES - FIRE DEPARTMENT APPROVAL OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION JOB ADDRF-SS 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 Contrartor pursuant -to the Contractors' State License Law). U 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 completionil 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:/lwww.leoinfo.ca.gov/calaw.html. Date: cr/2- ?p Si nature of Property Owner or Authorized Agent I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Sectioii"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 Code, I shall forthwith comply with those provisions Signa re of Appf 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 compiled 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. 1 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. SK�ure of Property Owner or Authorized Agent Date L/2_9 COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT DEPARTMENT OF PUALIC WORKS 9701 LAS TUNAS FIRE SPRINKLER BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 SL 0508 1503190029 PHONE: (626) 285-0488 EXT: LEGAL ID: NUMBER OF ADDED/RELOCATED BUILDING ADDRESS: TR: 5904 LT: 289 SQ. FT SPRINKLER HEADS 50 I 6139 ENCINITA AV ]STRUCTURE: 5209 TEMP CA 917801637 ASSESSOR INFORMATION NUMBER: ] NEAREST CROSS STREET: 5384-012-022 I ] THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY TENANT: I ]EXIST BLDG USE: ISSUED ON: PROCESSED BY: (EXIST OCC GAP: 103/19/15 SR OWNER: TEL. NO: IBLDGS. NOW ON IAT: VALUATION: IFINAL FINpL Byy` CODE: LEE, DANNY (626) 216-9110- 4,000 / ! 6139 ENCINITA AVE i //,91�/////W^/\I i� 6a TEMPLE CITY CA 91780 I FEES PAID I �CR DN K ]INSTALL FIRE SPRINKLER 13 D IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT:] APPLICANT: TEL. NO: I I LAW, KEN (626) 416-9276- IAA BLDG PERMIT ISSUANCE 27.80 I 2627 LOMA, AVENUE IAB STATE GREEN BLDG FEE 4000.00 VAL 1.00 (SPECIAL CONDITIONS: SOUTH EL MONTE IDO FIRE SPRINKLER PC 4000.00 VAL 98.40 ID2 PERMIT W/O EN-HC 4000.00 VAL 115.80 TOTAL FEES 243.00 CONTRACTOR: TEL. NO: ]APPROVALS DATE INSPECTOR SIGNATURE H T P C, INC. (626) 443-6366- ] 2627 LOMA AVE LIC. NO ]FIRE DEPARTMENT INSPECT SOUTH EL MONTE CA 91733 906249 C36 ] I IFIRE SPRINKLER RANGERS ARCHITECT OR ENGINEER: TEL. N0: I FIRE DEPARTMENT APPROVAL TCA ENGINEERING INC. (626) 571-4000- 8232 GARVEY AVE., #206 LIC. NO: ROSEMEAD, CA 91770 NONE I I ] MAP N0: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:] 001 NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: NO 20 SCHOOL WITHIN HAZARDOUS ] AIR QUALITY: 1000 FEET MATERIALS NO NO NO ] I I ] I I I I I 1 I � I I ]REPORT ID: DPR261 ] ROUTE TO: B50508 I I Ii I I i I I I I I I 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 (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 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 Contrbotor pursuant .to the Contractors' State License Law). U: 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 priori to completions 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.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 Incense is in full force and effect. p iccense ClassJLAo�_ License No. /(�% 2- � g � Date 3&Contractor Signature �— WORKERS' COMPENSATIONE�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 caner 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 forthwith comply with those provisions Sig 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 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. 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 matedals 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 ❑ Ro ❑ 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 ❑ 1 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). Lenders 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 owners 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 Applicant (Print Name) Applicant Signature Company Name Date —@ate