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Home My Public Portal About9523 BLACKLEY ST_ELECTRICAL_11/4/2015_COUNTY OF LOSIANGELES DEPARTMENT -OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT LEGAL ID: TR: 17190 LT: 9 ASSESSOR INFORMATION NUMBER 8590-005-011 HOFELING LAWRENCE L;MARJORIE J 9523 BLACKLEY ST TEMP 917803143 APPLICANT: TEL. NO: REVIVO, IRA (818) 510-1072- 18600 COLLINS ST BUILDING ADDRESS: TARZANA CA 91356 CONTRACTOR: TEL. N0: UNITED DESIGN BUILDERS INC (800) 608-1380- 1112 MONTANA AVE #535 LIC. NO SANTA MONICA, CA 90403 674543 I ARCHITECT OR ENGINEER: TEL. NO: LIC. NO EVIRED,q 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 TEMPLE CITY # 0508 9701 LAS TUNAS TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ELECTRICAL PERMIT EL 0508 1511040016 REPORT ID: DPR265 ROUTE TO: BS0508 IF'1NAL UA'1'G F'1NAL BY: CODE: DESCRIPTION OF WORK 14 LIGHT FIXTURES. GARBAGE DISPOSAL AND DISHWASHER I:q^Jq:aY1)�a. PLASTIC YIN METAL YIN UTILITY COMPANY NOTIFIED DATE INSPECTOR(( SIGNATURE FEES PAID BUILDING ADDRESS: 9523 BLACKLEY ST FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: TEMP CA 917803143 1 NEAREST CROSS STREET: Al PERMIT ISSUANCE FSE 27.80 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY 01 OUTLETS-LGT,SW,RECP 4.00 OUT 8.00 H2 RES GREG DISP LT 3HP 1.00 DIS 11.00 ON: PROCESSED BY: PLAN BY: H3 RES DISHWASHR LT 3HP 1.00 DIS 11.00 (ISSUED 11/04/15 SR TOTAL FEES 57.80 1 REPORT ID: DPR265 ROUTE TO: BS0508 IF'1NAL UA'1'G F'1NAL BY: CODE: DESCRIPTION OF WORK 14 LIGHT FIXTURES. GARBAGE DISPOSAL AND DISHWASHER I:q^Jq:aY1)�a. PLASTIC YIN METAL YIN UTILITY COMPANY NOTIFIED DATE INSPECTOR(( SIGNATURE OWNER -BUILDER DECLARATION 1 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 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 Contriar(tor 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 whic.� I must have resided for at least one year priorlto completion of the improvements covered by this permit, I c4nnot 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,/Aw/w.leoinfo.ca.aov/palaw.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 License No:4e8—tLts IJ Date 111; 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. _ZO 1 have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My ytprkers' compensation Insuranceterrier and poll of u j r are: CartPier olicy 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 pro�of Section 3700 of the Labor Code, I shall forthw' with those provisions re 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 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 SCAOMO 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). 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. Signat ty'dv�er or Authorized Agent Date ) t R^