HomeMy WebLinkAboutUntitled ,may
r•�'. Development Services Department
1,1, 240 West Huntington Drive,Post Office Box 60021
Arcadia, CA 91066-6021 PERMIT NO. B00-055-242
City of (626)574-5416 Fax(626)447-9173
Arcadia Permit Type: Tenant Improve w/energ;
PROJECT TRACT NO. LOT NO. APPLICATION DATE ISSUED BY PRINT DATE PERMIT STATUS
11/1/2016 CM 13:55 12/15/2016 Issued
ADDRESS NO. Dir.Prefix Street Name Street Suffix UNIT BLG ASSESSORS PARCEL NO. GEO CODE
400 S Baldwin Ave T-387
OWNER MAILING ADDRESS •
Westfield Corporation,Inc. 11601 Wilshire Blvd. 12th Floor PHONE NO. Plan Chk#: 16-505
Los Angeles,CA 90025- EMAIL ADDRESS:
Plan#: 32139
APPLICANT MAILING ADDRESS rt-
V T Construction PHONE NO.
EMAIL ADDRESS:
IAils1 TN
CONTRACTOR/PROFESSIONAL 'i AILI ' D ESS
V T Construction 1420 N Bristol St 220 PHONE NO. (714)330-0096 FAX NO.
Newport Beach,CA 92660 EMAIL ADDRESS:
License No. 590997 Type: A B C10 Expires: 3/31/2018 12:00:
TENANT MAILING ADDRESS
OSTM PHONE NO. FAX NO.
,
DESCRIPTION T I
T.l FOR OSIM,ELECTRICAL/MECHANICAL
Construction Type UOM k of Units Value Construction Type UOM N of Units Value
Value Value 100,000.00 $100,000.00
F,,,/4 -22-/7
OCCUPANCY: Tenant Improve TOTAL VALUATION: $100,000.00
QTY UOM DESC AMT AMT PAID ACCT QTY UOM DESC AMT AMT PAID ACCT
each Plan review 795.60 -795.60 01-3103 1.00 Flat SWMF 2 1.00 1.00 88-3027
each Energy p/c fee 244.80 244.80 01-3103
PC ADA 119.34 119.34 01-3103
PC Cal Green 79.56 79.56 01-3103
1.00 Flat Bldg Issue Auto 44.35 44.35 01-3104
each Bldg permit 1,224.00 1,224.00 01-3104
Bldg Issue ADA 122.40 122.40 01-3104
1.00 Flat Elec issue 44.35 44.35 01-3105
1.00 Flat Mech issue 44.35• 44.35 01-3105
16.00 each Outlets 24.64 24.64 01-3105
26.00 each Ltg fixtures 36.80 36.80 01-3105
8.00 Flat Add/Alter Ducts 75.04 75.04 01-3105
1.00 each T.I.Fire Pkc 255.00 255.00 01-3109
SMIP Corn 28.00 28.00 14-2207
gm bldg std 4.00 4.00 714-2203
1.00 Flat SWMF Auto 6.25 6.25 88-3027
1.00 Flat SWMF 2 1.00 1.00 88-3027
Total Fees: $3,150.48 Balance Due: $0.00 Paid Today: $1,656.18
This permit/plan review expires by time limitation and becomes null and void if the work authorized by the Receipt#: 115309
permit is not commenced within 180 days from the date of issuance or if the permit is not obtained within 180 days from 01-3104 1,390.75
the date of plan submittal.This permit expires and becomes null and void if any work authorized by this permit 01-3105 225.18
is suspended or abandoned for 180 consecutive days or if no progressive work has been verified by a City of 14-2207 28.00
Arcadia building inspector for a period of 180 consecutive days. 714-2203 4.00
88-3027 8.25
CALLS FOR INSPECTION INSPECTORS'OFFICE HOURS /
Requests for inspection should be made at least Monday-Thursday Friday
one(1)business day in advance of the inspection 7:30 a.m.to 8:30 a.m. 7:30 a.m.to 8:30 a.m.
by telephone at(626)574-5416 for onsite work. 4:00 p.m.to 5:30 p.m. 4:00 p.m.to 4:30 p.m.
(Closed on alternate Fridays)
OF Age .. .,
% O44, PI,IFO .,,"9Ar
CI
_, VVI' PERMIT/PLAN REVIEW APPLICATION
24 OA WM/ WO
o i Development Services Department,240 West Huntington Drive,Post Office Box 60021
0.4,,,,of v° Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions Code,and my license is in full force and effect. 0 I have and will maintain a certificate of consent to self-insure for workers'
License Class AO( /0 Li n e No. ��b 9 g 7 Exp. Date-SA/AS compensation, as provided for by Section 3700 of the Labor Code, for the
��i performance of the work for which this permit is issued.
i nature of Contractor C /t�Ul�
OWNER-BUILDER DECLAFLN ❑ I have and will maintain workers'compensation insurance,as required by Section
❑ I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier TA-7e FU NP (7A 1 r.
demolish,or repair any structure,prior to its issuance,also required the applicant / /tel('53 �J///
for such permit to file a signed statement that he or she is licensed pursuant to the Policy Number _/
provisions of the Contractors License Law(Chapter 9(commencing with Section is section need not be completed if the p rmit is for one hundred dollars or less)
7000)of Division 3 of the Business and Professions Code) or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of ❑II certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): 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
❑I, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions.
compensation,will do the work,and the structure is not intended or offered for
sale(Section 7044,Business and Professions Code:The Contractors License Date Signature
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful,
sale.If,however,the building or improvement is sold within one(1)year of and shall subject an employer to criminal penalties and civil fines up to one
`completion,the owner-builder will have the burden of proving that he or she hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
❑I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044, Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon, and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
❑ I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos. Please contact AQMD at(909)396-2000 for
further information.
(came V/a/AVJ e 7R#A) Title -R?6 /1) r
PRINT NAME
I certify that I have read this application and state that the above information is correct and that I am the owner or duly authorized agent of the owner.
I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter u on t e above-mentioned property for inspection purposes.
•
ignaturea /2/5//-
c/
çDate
NOTES
Building Inspections Date Insp. Plumbing Inspections Date Insp.
100. Setbacks 210. Under ft./bldg.drain ,,��
101. Rough grade 211. Copper underslab 2 2�/7 1/Ryt> au__c5-r(
102. Figs.&forms 212. Rough plumbing
103. Pre-slab I--3-n b+.->/ 213. Rough gas
104. Floor joists 214. Shower pan
105. Steel 215. Water heater I s 17 GCL_4PL6 FRAM` kx,
-
106. Grout lift 216. Roof drains
107. Shear nailing 217. Building sewer
108. Diaph nailing 218. Water service
109. Roof nailing 219. Final gas
110. Framing 14341 /1 „ 220. Fixtures - - -
111. 0cc./Area Sept.Wall (�^'f/ 221. Final plumbing
112. Sound walls 222. Sewer cap/demo.
113. T-bar grid
114. Insulation-Flr. Pool Inspections Date I: Insp.
115. Insulation-Wall 240. Excavation/steel
116. Insulation-Ceil. 241. Rough plumbing
117. Drywall nailing 2-/a-/7 242. Light shell/bonding
118. Interior lath 243. Underground conduit
119. Exterior lath 244. P-trap
•
120. Finish grade ;45. Gas line&test
121. Final building 3-22-17 246. Fence,gates&signs
122. Final demo/lot clear 247. Pool heater
248. Final electric
Electrical Inspections Date . Insp. 249. Final dumbing
150. Power pole 250. Pool cover
151. Sales lot lighting 251. Pool final
152. Underground conduit
153. Underslab conduit 1-el-17 Reroof Inspections Date I Insp.
154. UFER ground 270. Pre-reroof insp.
155. Water ground 271. Roof framing
156. Rough electrical j►-7 272. Sheathing nailing
157. Fixtures 273. Final reroof
158. G.F.C.I.
159. E••t.bondin• Sign Inspections I Date I Insp.
160. Service panel 280. Setback/overhang
161. Final electric 3-224? 281. Footing
282. Conduit/wiring
Mechanical Inspections Date Insp." 283. Disconnect
180. Venting/flue 284. Final sign
181. Furnace/A.C.
182. Rouch HVAC I-/9 f i Miscellaneous Insp. I Date I Insp.
183. Fire dampers 290. Fire alarm
184. Furnace compartment 291. Underground supply
185. Combustion air 292. Fire sprinklers
186. Smoke detectors 293. Monitor system
187. Metal F.P,rough 294. Hood dry chem.
188. Compressor setback 295. Final
189. Commercial hood
190. Duct shaft Sewers&Offsite Insp. Date I Insp.
191. Final mechanicalZZ`7,�i 300. Lateral(main to P/L)
301. Saddle/Y •
Block Wall Inspections Date Insp. 302. Cess•ool filled
200. Footings 303. Sidewalk
201. Steel/rebar 304. Driveway
202. Grout lift 305. Curb replacement
203. Final wall 306. Trash bin
r, ,, ® .�;�1r,ft M, `'11.'; �n i ��}.!�`1 .e�:,i,���� iit�d� t�V ar � Fh.r. / : �{,r � �tiii {�.-1 it ; --- 31sUj Nt ,fid f Lh1 �irif4c, _ .A\0flit .,.; .:l k�i[4,: s`vV1ll1 s 1 ,a�" )j I:.,r�jry+,_l ,, aF► `l t, .lI `� 1, .I ` , • , r -` , ` 4r � t �► it � �► tt � l tr V 1 ®fit IRA l �" M er 1 .® t�-'- ttii• =
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Certificate to of Occupancy
((1-1 :':; 804 1
0'1,
v �l City of Arcadia ye
�+ Q Development Services Department - Building Division
ala
This certificate issued pursuant to the requirements of Section 109 of the
•
Uniform Building Code certifying that at the time of issuance this structure was in0111
compliance with the various ordinances of the City regulating building construction or use.
1 igrei
As
gri® Permit No. B00-055-242 ,or--,))41.*7
/w BuildingAddress: t1
,r Jnr 400 S Baldwin Ave,Arcadia,CA 91007
rll s'
Use Classification: Tenant Effective UBC: r
o-, ImproveC.B.C.2013 ,
1 i 1. PermitType: Tenant Improve w/ener Zone Code: r �iit
' ,,��) ' P by C2-DH8 irk ,,
� , Occupancy Code: M Type of Construction: TYPE II IHR SPRINKLERED %-
Final Date: 3/22/2017
,i., -
Arig Owner:
Westfield Corporation, Inc. I. ,,v
Iilk'fit Tenant: OA
Osim II
1/4,r0v.... ...L., --__________
Don Stockham,Building
r, ,,
. ate
11 wez.reiti
'fi��IL'I � POST IN A CONSPICUOUS PLACE I,�:;,
Pit :
a
helii ,:, . . . . iv' ,,,y,
1 1 ski 1 i 1 ! ;1 1s rwi1 1 , 110 �+ 77..,,I,i-
- 1 r� 11r r t� '� rLt •r r. Ittl r r It t1 w r It t1' J,1 ��\l - /4��.t :..> s�as�.;;. -,j 7 r ;�aC. N�q jnt��, r '`'qtr+t li!\\=,^.. �fa� 14#4710,41100101w1
a r ` �9� ' t .. �.� , -.010,,,,,!:11 - pl.lr; :tip
c'�7PJ�f 11.4.1}�i 'V_hl.
Development Services Department
24
. �, 0 West Huntington Drive,Post Office Box 60021 PERMIT NO.
'1 „.561 Arcadia, CA 91066-6021 BOO-056-057
City of (626) 574-5416 Fax(626)447-9173
Arcadia Permit Type: Fire
PROJECT TRACT NO. LOT NO. APPLICATION DATE ISSUED BY PRINT DATE PERMIT STATUS
2/13/2017 CM 9:39 2/13/2017 Issued
ADDRESS NO. Dir.Prefix Street Name Street Suffix UNIT BLG ASSESSORS PARCEL NO. GEO CODE
400 S Baldwin Ave T-387
OWNER MAILING ADDRESS
Westfield Corporation,Inc. 11601 Wilshire Blvd. 12th Floor PHONE NO.
Los Angeles,CA 90025- EMAIL ADDRESS:
APPLICANT MAILING ADDRESS
Hydro-Matic Fire Protection PHONE NO.
EMAIL ADDRESS:
r
CONTRACTOR/PROFESSIONAL MAILING ADDRESS
Hydro-Matic Fire Protection 116 &T•-.m da; 1 0,i`11 PHONE NO. (818)247-9812 FAX NO.
Gle fiz- f A ; ]4 0: EMAIL ADDRESS:
License No. 718393 Type: C-16 Ex: . . .131G•F .
TENANT MAILING ADDRESS •
Osim PHONE NO. FAX NO.
'
DESCRIPTION
FIRE SPRINKLERS FOR OSIM
Construction Type UOM #of Units Value Construction Type UOM /of Units Value
Value Value 1,500.00 $1,500.00
OCCUPANCY: Fire Sprink/Alm TOTAL VALUATION: $1,500.00
QTY UOM DESC AMT AMT PAID ACCT QTY UOM DESC AMT AMT PAID ACCT
11.00 each sprinkler pck 700.00 700.00 01-3109
1.00 Flat Fire Issue Auto 44.35 44.35 01-3112
each Fire Permit 82.65 82.65 01-3112
1.00 each SWMF 2 Auto 1.00 1.00 88-3027
•
Total Fees: $828.00 Balance Due: $0.00 Paid Today: $828.00
This permit/plan review expires by time limitation and becomes null and void if the work authorized by the Receipt#: 115803
permit is not commenced within 180 days from the date of issuance or if the permit is not obtained within 180 days from 01-3109 700.00
the date of plan submittal.This permit expires and becomes null and void if any work authorized by this permit 01-3112 127.00
is suspended or abandoned for 180 consecutive days or if no progressive work has been verified by a City of 88-3027 1.00
Arcadia building inspector for a period of 180 consecutive days.
CALLS FOR INSPECTION INSPECTORS'OFFICE HOURS l_ .
Requests for inspection should be made at least Monday-Thursday Friday I
N\ \ •
one(1)business day in advance of the inspection 7:30 a.m.to 8:30 a.m. 7:30 a.m.to 8:30 a.m.
by telephone at(626)574-5416 for onsite work. 4:00 p.m.to 5:30 p.m. 4:00 p.m.to 4:30 p.m.
(Closed on alternate Fridays) )
pF ARC4 TuFORN�9
` og
d
U9n
PERMIT/PLAN REVIEW APPLICATION
, �j. Development Services Department,240 West Huntington Drive,Post Office Box 60021
'-,.,,,ofw' Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DE ( ARATION WORKERS'COMPENSATION DECLARATION
I hereby affirm under penalty of perjury t =.I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7041,of Division 3 of the Business and
Professions Code,and my license' in/ force and effect. I have and will maintain a certificate of consent to self-insure for workers'
License Class 5•- i'-ns- !�.. i Exp. Date/3o1'•'k compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Signature of Contractor � / 4
OWNER-BUILDER DE LA° TIO ❑ I have and will maintain workers'compensation insurance,as required by Section
CII hereby affirm under penalty of perj ry that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the following reason(Section 7031.5,Business and Professions is issued.My Workers'compenssainsurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier '''i 1 LZ�l`ntion.f
demolish,or repair any structure,prior to its issuance,also required the applicant
for such permit to file a signed statement that he or she is licensed pursuant to the Policy Number
provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less)
7000) of Division 3 of the Business and Professions Code)or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit i 'sued shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subje t. th Ire rkers'
penalty of not more than five hundred dollars($500)): compensation Laws of California,and agree that if I.hould. co 'e .,-ct to the
workers'compensation provisions of Section 10 of e La.,. .de,I shall
❑I, as owner of the property, or my employees with wages as their sole forthwith comply with those provision
compensation,will do the work,and the structure is not intended or offered for /
sale(Section 7044,Business and Professions Code:The Contractors License Date 2.4J 1 Signature / I
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own - —- -
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful,
sale.If,however,the building or improvement is sold within one(1)year of and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he or she hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
❑I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044, Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
❑ I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos.Please contact AQMD at(909) 396-2000 for
further information.
Name L i d / — ;U 4.! ..!4 46-0 Title GQ .Q )'QCZne.--
PRINT NAME
I certify that I have read t s applica •s 1 and'st.to that the above information is correct and that I am the owner or duly authorized agent of the owner.
I agree to comply th :11 City •rd* aces .nd State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter on e ab u •-me •i nejjperty for inspection purposes.
Signature i Date 3 1
g p / /—1
a y,.. Development Services Department
1. ! .1 240 West Huntington Drive,Post Office Box 60021
a..<< Arcadia, CA 91066-6021 PERMIT NO: . BOO-056-129
City of (626) 574-5416,Fax(626)447-9173
ArcadiaPermit Type: Fire
PROJECT TRACT NO. LOT NO. APPLICATION DATE ISSUED BY PRINT DATE PERMIT STATUS
2/23/2017 EP 11:27 2/23/2017 Issued
ADDRESS NO. Dir.Prefix-. Street Name !. Street Suffix UNIT :BLG ASSESSORS PARCEL NO. GEO CODE
400 S Baldwin Ave T-387
OWNER - ',... MAILING ADDRESS
Westfield Corporation, Inc. 11601 Wilshire Blvd. 12th Floor PHONE NO. Plan Chk#: OTC
Los Angeles,CA 90025- EMAIL ADDRESS:
APPLICANT MAILING ADDRESS
Building Electronic Controls Inc. PHONE NO.
EMAIL ADDRESS:
'
CONTRACTOR/PROFESSIONAL M ` i..RE 18
Building Electronic Controls Inc. 2)7.41d'. ,'f i�;,�+i LET PHONE NO. FAX NO.
iii444
Gn, f.'
„, EMAIL ADDRESS:
License No. 729905 Type: C Expires: 11/30/2018 12:0(
TENANT - 'MAILING ADDRESS
OSIm PHONE NO. FAX NO.
,
DESCRIPTION
FIRE DEVICES FOR OSIM 5 DEVICES
Construction Type UOM #of Units Value Construction Type UOM #of Units Value
Value Value 7,000.00 $7,000.00
OCCUPANCY: Fire Sprink/Alm TOTAL VALUATION: $7,000.00
QTY UOM DESC AMT AMT PAID ACCT QTY UOM DESC AMT AMT PAID ACCT
5.00 each fire alarm pe 2 280.00 280.00 01-3109
1.00 Flat Fire Issue Auto 44.35 44.35 01-3112
each Fire Permit 187.15 187.15 01-3112
1.00 each SWMF 2 Auto 1.00 1.00 88-3027
Total Fees: $512.50 Balance Due: $0.00 Paid Today: $512.50
This permit/plan review expires by time limitation and becomes null and void if the work authorized by the Receipt#: 115893
permit is not commenced within 180 days from the date of issuance or if the permit is not obtained within 180 days from 01-3109 280.00
the date of plan submittal.This permit expires and becomes null and void if any work authorized by this permit 01-3112 231.50
is suspended or abandoned for 180 consecutive days or if no progressive work has been verified by a City of 88-3027 1.00
Arcadia building inspector for a period of 180 consecutive days.
CALLS FOR INSPECTION INSPECTORS'OFFICE HOURS 4/,Requests for inspection should be made at least Monday-Thursday Friday
one(1)business day in advance of the inspection 7:30 a.m.to 8:30 a.m. 7:30 a.m.to 8:30 a.m. /
by telephone at(626)574-5416 for onsite work. 4:00 p.m.to 5:30 p.m. 4:00 p.m.to 4:30 p.m.
(Closed on alternate Fridays)
ARC
G~�oFF ,0 y
a;: PERMIT/PLAN REVIEW APPLICATION
WA IrE Development Services Department,240 West Huntington Drive,Post Office Box 60021
4.*4'..,,y o[N° Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
rofessions Code,and my license is in full force and effect. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class G`O License No.-1'ZCVa[L S i Date\\I36/ compensation, as provided for by Section 3700 of the Labor Code, for the
1 ,� t ` ,�\/�{�� performance of the work for which this permit is issued.
141 Signature of Contractor —
OWNER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section
❑ I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the following reason(Section 7031.5,Business and Professions s issued.My workers'compensation surance carrier ad policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrierec\GaitrN Ni . `Us► r ‘4\iN
demolish,or repair any structure,prior to its issuance,also required the applicant (� Z`� E
for such permit to file a signed statement that he or she is licensed pursuant to the olicy Number
provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less)
7000) of Division 3 of the Business and Professions Code) or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): 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
❑I, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions.
compensation,will do the work,and the structure is not intended or offered for
sale(Section 7044,Business and Professions Code:The Contractors License Date Signature
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful,
sale.If,however,the building or improvement is sold within one(1)year of and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he or she hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
❑I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
❑ I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos. Please contact AQMD at(909) 396-2000 for
further information.
(Name `n (Title /
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PRINT NA
I certify that I have read this application and state that the above information is correct and that I am the owner or duly authorized agent of the owner.
I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter upon the above-mentioned 8 roperty for inspection purposes.
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