HomeMy WebLinkAboutUntitled (2) BUILDING AND SAFETY DIVISION
City of Arcadia MISCELLANF4)US AND OFF-SITE
240 W. HUNTINGTON DR., ARCADIA, CA 91006 • TEL. (818)574-5416 PERMIT
"Budding c fn� MISCELLANEOUS FEE RECEIPT 1
Owner n Q ,,., - 0 # PLAN CHECK FEE FOR VAL.
�00tel fi k `' ...\tl07 /Inn Cr(ccll
Moiling I�y�/r / 0 CASH BOND FOR
Address �CO C; Q"-'\ R•Ortt.k 2
City Zip Tel. 0 GRADING PLAN CHECK _
0rC_c‘ eltoA.___ 9/004; -1Y,--Aq >?
Controcra 0 GRADING PERMIT -
Address 0 HOUSE MOVING
City Zip I Tel.
0 PARKS AND RECREATION FEE
ROUTE INS ECTION FEE
Stole Lit. City n /x.2.7/6 r1 B Clossil. l Lit. No. g /L/i'G�'r�y1 ��� C<<G-t 6)e go-
Q01LICENSED CON1RACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section
7(SAfI)of Division 3 of the Business and Professions Code,and my licence is in full force and
effect.
0 r
OWNER-BUILDER DECLARATION �)
TOTAL FEE $ r V
❑ I hereby affirm that I am exempt from the Contractor's License Law for the following
reason:"Sec.703/.5.Business and Professions Codes.Any city or county which requires a ilE WARNING I PLAN CHECK FEES. WHERE NO ACTION IS TAKEN BY THE
permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance APPLICANT IN 180 DAYS AND NO BUILDING PERMIT IS ISSUED,FEES ARE
also requires the applicant for such permit to file a signed statement that he is licensed FORFEITED TO-THE CITY.
pursuant to the provisions of the Contractor's License Law.Chapter 9(commencing with
Section 7000)of Division 3 of the Business and Professions Code, or that he is exempt
therefrom,and the basis for the alleged exemption.Any violation of Section 7031.5 by any SEWER PERMIT
applicant for a permit,subjects the applicant to a civil penalty of not more than five hundred PERMISSION IS HEREBY GRANTED TO MAKE SEWER CONNECTIONS AT
dollars($500).''
PI,as owner of the property,or my employees with wages as their sole compensation,will
o the work,and the structure is not intended or offered for sale."Sec.7044,Business and
Professions Code:The Contractor's License Law does no/apply roan owner of property who LOT BLOCK TRACT
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the LOCATION LATERAL
building or improvement is sold within one year of completion,the owner-builder will have SADDLE
the burden of proving that he did not build or improve for the purpose of sale.'' SEWER PLAN NO. CESSPOOL FILL +
ElI,I, as owner of the property, am exclusively contracting with licensed contractor to $ 3.00
construct the project."Sec.7044,Business and Professions Code:The Contractor's License
Law does not apply to an owner of property who builds or improves thereon,and who con-
tracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.'' INSPECTED )98 $
El I am excempt under Sec._— _---_,B.&P.C.for the reason
TOTAL
BY BY T
■.....tr
CURB AND SIDEWALK
Date _____Owner
WORKERS'COMPENSATION DECLARATION CURB BREAK REPLACE CURB FT.
I hereby affirm that I have a certificate of consent to self-insure,or a certificate of
Worker's Compensation Insurance,or a certified copy thereof.(Sec:3800.Labor Code.)
Policy No. Company DRIVEWAY APPROACH _ SIDEWALK FT.
0 Copy is filed Certified copy is Exp.Date
with the City. 0 hereby furnished. I INSPECTED TOTAL FEE I
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATION INSURANCE STREET CUT
_ (This section need not be completed if the permit is for one hundred dollars($100)or less.)
Z ❑ I certify that in the performance of the work for which this permit is issued.I shall not ESTIMATED SIZE OF PATCH AMOUNT OF DEPOSIT
(n employ any person in any manner so as to become subject to the Workers'Compensation Law
"t of California. /S0.FT.
rfl NOTICE TO APPLICANT:If,after making this Certificate of Exemption you should become ACTUAL SIZE.OF PATCH AMOUNT CHARGED
C') subject to the Workers' Compensation provisions of the Labor Code,you must forthwith ® /SO.FT.
—1 comply with each provisions or this permit shall be deemed revoked. AMOUNT REFUNDED
0 I certify that I have read this application and state that the above information is correct.I RECEIVED FROM STREET DEPT.
agree to comply with all city and county ordinances and state laws relating to building INSPECTION FEE
construction,and hereby authorize representatives of this city to enter the above-mentioned
0) property for inspection purposes. y�,,_ INSPECTED 198 BY
0 Signature of Applicant-j _ 73 Date�7. � PERMIT FEE
Mailing Address TOTAL FEES
ikliCi-ity,State,Zip
17'
This is a building permit when properly filled out, signed and validated, 06-96-87 1.CL4939 TOTAL 3 tS a 80
and is subject to expiration if work thereunder is suspended for 180 days.
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