HomeMy Public PortalAbout9548 Las Tunas Dr_Building_3/13/2014_`- COUNTY OF'LOS1ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
1TR: 6561 LT: 638 BL: .001
1
ASSESSOR INFORMATION NUMBER:
18587-015-019
1
1TENANT:
1
1
(OWNER:
TEL. NO:
1LI, JEN KAO
(626) 446-2358-
1923 S 6TH AVENUE
IARCADIA CA 91006
1
(APPLICANT:
I
TEL. NO:
1FANG, KEN
(909) 569-2069-
118888 LABIN CT B 213
1ROWLAND HEIGHTS
1CONTRACTOR:
TEL. NO:
1CHAPPOS CONSTRUCTION INC
(818) 253-6728-
123518 BALMORAL LN
LIC. NO
1WEST HILLS CA 91307
1
714085
1
(ARCHITECT OR ENGINEER:
TEL. NO:
1KECHUNG CHQU
(626) 826-0055-
118888 LABIN CT B 213
LIC. NO:
1ROWLAND HEIGHTS CA
I
C27103
�
I
1MAP NO: SEWER MAP BOOK: PAGE:
�
FIRE ZONE: CMP:(
j
3 001
1NO. OF FAMILIES: DWELLING UNITS:
APT/COND: STAT CLASS:
0
NO 22
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 NEW
SQ. FT STORIES TYPE OCCUP GROUP
STRUCTURE: 3593 1 V -B B
EXIST BLDG USE: COMME USE ZONE:
EXIST OCC GRP: B
BLDGS. NOW ON LOT: VALUATION:
50,000
FEES PAID
FEE DESCRIPTION: QUANTITY: UOM
Al PLANCHECK W/EN-HC 50000.00 VAL
AA BLDG PERMIT ISSUANCE
AB STATE GREEN BLDG FEE 50000.00 VAL
AE STRONG MOTION OTHER 50000.00 VAL
A2 PERMIT W/ENERGY-HC 50000.00 VAL
TOTAL FEES
REPORT ID: DPR261 ROUTE TO: BS0508
AMOUNT:
781.10
27.80
2.00
10.50
918.90
1,740.30
BUILDING PERMIT
TENANT IMPROVEMENT
BL 0508 1401160050
BUILDING ADDRESS:
9548 LAS TUNAS DR
TEMP CA 917802106
NEAREST CROSS STREET:
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CA
ISSUED ON: PROCESSED BY:
03/13/14 SR
F NALD�� FINAL BY: CODE:
D SCRIPTION OF WORK v
TENANT IMPROVEMENT LOW PARTITION WALL, EXISTING "T" BAR
CEILING REMAIN NO CHANGE EXISTING H.C. RESTROOM REMAIN NO
CHANGE
SPECIAL CONDITIONS:
APPROVALS
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
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T -BAR CEILINGS
LOT DRAINAGE
DATE INSPECTOR SIGNATURE
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 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). '
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 leas
one year prior) to completion; of the improvements covered
this permit, I c nnot legally sell a structure that I have built as a
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.aov/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.
Date ctor Si ure
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
., 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 a become subject to the workers' compensation laws of
iforni ,and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Co . .dl hi -I II ir.; with those provisions
�3 2�
Signature of Applicant Da
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 ❑ 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-ide d- 'nspection purposes.
Signature of Property Own orized Agent
Date 3 R
COUNTY OF'LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
TR: 6561 LT: 638 BL: .001
ASSESSOR INFORMATION NUMBER:
8587-015-019
TENANT:
OWNER:
LI, JEN KAO
923 S 6TH AVENUE
ARCADIA CA 91006
APPLICANT:
CHEN, MAN LIANG
893 N WHITE HOUSE CI
WALNUT CA 91789
CONTRACTOR:
MLC CONSTRUCTION, INC.
893 N WHITE HORSE CIRCLE
WALNUT CA 91789
ARCHITECT OR ENGINEER:
KECHUNG CHOU
18888 LABIN CT B 213
ROWLAND HEIGHTS CA
TEL. NO:
(626) 446 -2358 -
TEL. NO:
(626) 390 -5858 -
TEMPLE CITY
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
{ NO. OF CONST
{ SQ. FT STORIES TYPE
{STRUCTURE: 3593 2 V -B
GARAGE:
OTHER:
EXIST BLDG USE: COMME
EXIST OCC GRP: B
JBLDGS. NOW ON LOT:
TEL. NO:
(626) 390 -5858 -
LIC. NO {
928009
{
TEL. NO: {
(626) 826-0055- {
LIC. NO: {
C27103
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
NO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS:
0 NO 99
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO
I
FEE DESCRIPTION:
AA BLDG PERMIT ISSUANCE
REPORT ID: DPR261
# 0508
BUILDING PERMIT
BL 0508 1405280084
NEW { BUILDING ADDRESS: {
OCCUP GROUP{ 9548 LAS TUNAS DR {
B { TEMP CA 917802106 {
{ NEAREST CROSS STREET:
{ THOMAS PAGE: 596 GP.ID: J3 LOCALITY: TEMPLE CITY CA{
{ {
ISSUED ON: PROCESSED BY: {
105/28/14 SR {
VALUATION: {FINAL DATE F BY: CODE: {
50,000 1
FEES PAID IDtSCRIPTION OF WORK IV
{CHANGE CONTRACTOR SEE ALSO BL 1401160050- TANANT IMPROVEMENT{
QUANTITY: UOM: AMOUNT:{LOW PARTITIONS WALL, EXISTING "T" BAR CEILING REMAIN NO {
{CHANGE EXISTING H.C. RESTROOM REMAIN NO CHANGE {
27.80 { {
TOTAL FEES 27.80 {SPECIAL CONDITIONS: {
{APPROVALS 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 { { {
{ { {A 14{
{FRAME INSPECTION {
{FIRE SPRINKLER HANGERS { {
{INSULATION/WEATHER STRIP) { {
{ { { {
{INTERIOR LATH/DRYWALL { { {
{EXTERIOR LATH { { {
{RATED FLOOR/CEIL ASSEM. {
RATED WALL ASSEMBLIES { {
RATED SHAFTS/OPENINGS { {
{T -BAR CEILINGS {
{LOT DRAINAGE { { {
ROUTE TO: BS0508 { { {
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 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 Contr'aGtor 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 priorlto completion, of the improvements covered by
this permit, I cnnot 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.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. 1 D J I
Date rector Signature
ORKERS' 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
Siggnature of Applicant
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 ❑ N o ❑ j
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 toIeach 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 Owner or Authorized Agent
/g /t
Date X-144
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
ITR: 6561 LT: 638 BL: .001
I
ASSESSOR INFORMATION NUMBER:
VAL
18587-015-019
7000.00
I
TENANT:
I
1.50
I
OWNER:
TEL. NO:
ILI, JEN KAO
(626) 446-2358-
1923 S 6TH AVENUE
191.10
IARCADIA CA 91006
APPLICANT:
TEL. NO:
ICHEN, MAN LIANG
(626) 390-5858-
1893 N WHITE HOUSE CI
WALNUT CA 91789
CONTRACTOR:
TEL. NO:
IMLC CONSTRUCTION, INC.
(626) 390-5858-
1893 N WHITE HORSE CIRCLE
LIC. NO
WALNUT CA 91789
928009
ARCHITECT OR ENGINEER:
TEL. NO:
IKECHUNG CHOU
(626) 826-0055-
118888 LABIN CT B 213
LIC. NO:
IROWLAND HEIGHTS CA
C27103
IMAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMP:
3 00
INO. OF FAMILIES: DWELLING UNITS:
APT/GOND: STAT CLASS:
1 0
NO 22
SCHOOL WITHIN HAZARDOUS
(AIR QUALITY: 1000 FEET MATERIALS
I NO NO NO
TEMPLE CITY # 0508 BUILDING PERMIT
9701 LAS TUNAS TENANT IMPROVEMENT
TEMPLE CITY CA 91780 BL 0508 1405010085
PHONE: (626) 285-0488 EXT:
NO. OF CONST NEW BUILDING ADDRESS:
SQ. FT STORIES TYPE OCCUP GROUP 9548 LAS TUNAS DR
STRUCTURE: 3593 1 V -B B I TEMP CA 917802106
NEAREST CROSS STREET:
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CAI
I
EXIST BLDG USE: COMME
EXIST OCC GRP: B
BLDGS. NOW ON LOT:
FEE DESCRIPTION:
AA BLDG PERMIT ISSUANCE
AB STATE GREEN BLDG FEE
AE STRONG MOTION OTHER
Al PLANCHECK W/EN-HC
A2 PERMIT W/ENERGY-HC
REPORT ID: DPR261
USE ZONE: (ISSUED ON: PROCESSED BY:
105/28/14 SR
VALUATION: IFINAL DATE_ FINAL BY: CODE:
7,000
FEES PAID IDLSftIPTION OF WORK
INSTALL SOFFTS & DRYWALL CE LING IN BACK ROOM AT BUILDING
QUANTITY: UOM: AMOUNT:IAND OVER RECEPTION AREA
I I
ROUTE TO: BS0508
SPECIAL CONDITIONS:
APPROVALS
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
I
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
IFLOOR SHEATHING
IROOF SHEATHING
ISHEAR PANELS
I
IFRAME INSPECTION
IFIRE SPRINKLER HANGERS
IINSULATION/WEATHER STRIP
IINTERIOR LATH/DRYWALL
(EXTERIOR LATH
I-
IRATED FLOOR/CEIL ASSEM.
I
IRATED WALL ASSEMBLIES
I
IRATED SHAFTS/OPENINGS
I
IT -BAR CEILINGS
I
ILOT DRAINAGE
DATE INSPECTOR SIGNATURE
27.80
7000.00
VAL
1.00
7000.00
VAL
1.50
7000.00
VAL
162.50
7000.00
VAL
191.10
TOTAL FEES
383.90
ROUTE TO: BS0508
SPECIAL CONDITIONS:
APPROVALS
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
I
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
IFLOOR SHEATHING
IROOF SHEATHING
ISHEAR PANELS
I
IFRAME INSPECTION
IFIRE SPRINKLER HANGERS
IINSULATION/WEATHER STRIP
IINTERIOR LATH/DRYWALL
(EXTERIOR LATH
I-
IRATED FLOOR/CEIL ASSEM.
I
IRATED WALL ASSEMBLIES
I
IRATED SHAFTS/OPENINGS
I
IT -BAR CEILINGS
I
ILOT DRAINAGE
DATE INSPECTOR SIGNATURE
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 L) 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 Will: 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 Contrec[or 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 whict 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 contacted 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.leoinfo.meaov/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.
LiceW�tractor
License No.
DatSignature
WORKERS' COMPENSATION DECLARATION
WANING: 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:
Cartier 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
/ r /44h �
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 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 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).
Lenders 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 Property Owner or uthwized Agent
Date