HomeMy WebLinkAboutUntitled '' City of Arcadia, CA 0� 1, = Perm,tN0 RALT 18 0193;
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Development Services Department - �° PermiCT a Residential Addition Alteration
240 West Huntington Drive,Post Office Box 60021 , € 1 I", k4", ' 4 -4 u;" 0. / X7'11
( �; Arcadia,CA 91066-6021 S'= 1 tko kCIassIfcati0rl:Addition/Atte ilatlon
0 (626)574-5416 , s .�s�, m to TMx_ x tit
'? � i� i, ,,„, 1 4 Permit.`Statusv issued
ARCADIA °issue Date 02/22/20181 Expiration: 08/21/2018
.iii ,, _
Addr NO. Dir Prefix Street Name Street Suffix City,State,Zip Parcel Number
28 E Santa Anita TER Arcadia,CA 5781001033 a
Contacts
KIM,JAE K AND MIA Owner is
28 E SANTA ANITA TER
-. ._.,
Description:RESTORE BACK TO APPROVED ROOM AND Valuation: $ 500.00 Tenant a
.. a: ai
BREEZEWAY PER 1962 APPROVED PLAN y
Total Sq Feet: 0.00 Plan Check# Plan#
Fees Amount Payments Amount Paid
Building Issuing Fee $44.35 Total Fees $92.75
Building Permit Fees $40.65 Cash/Receipt# $92.75
Green Building Standard $1.00
Solid Waste Management Fee $6.25 Amount Due: $0.00
Strong Motion Inst.Program Res $0.50
Total: $92.75
t—LZ 1 k
CALLS FOR INSPECTION Request for inspection by telephone at 626-574-5450.
.IA- A Leave a message requesting the address,time frame and what inspection
'V C� item is needed.
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 consecutive days.
' . T
co
February 22,2018
Issued By: Date
February 22,2018 Page 1 of 2
47
coF + ,4,
~v
PERMIT/PLAN REVIEW APPLICATION
Oki IFFEEEM 'IP
`441.1' ; Development Services Department,240 West Huntington Drive,Post Office Box 60021
\Y.----e. 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. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class License No. Exp. Date compensation, as provided for by Section 3700 of the Labor Code, for the
Signature of Contractor performance of the work for which this permit is issued.
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 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
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 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,2—17 / S 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 qr 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 -- d Signature ‘. Lender's Address
IMPORTANT: APPIiICATION 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 Si4 6 !- • rC/ 44 Title
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 upon the above-mentioned property for inspection purposes.
Signature Date
1
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- ;'
City of Arcadia, CA
Permit NO MEP-180615
Development Services Department �'"° ! Permit Type; MEP
240 West Huntington Drive,Post Office Box 60021 ) � r
'.'Work Classification MEP Residential
ao Arcadia,CA 91066-6021 -
(626)574-5416 1' PermitStatus"Issued
ARC AIA.
�� Issue nate 04/19/2018 Expiration: 10/16/2018
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
28 E Santa Anita TER Arcadia,CA 5781001033
Contacts
KIM,JAE K AND MIA Owner
28 E SANTA ANITA TER
(213)235-7266
Description:ELECTRICAL AND PLUMBING FOR SMALL 3 Valuation: S 0.00 Tenant
ADDITION
Total Sq Feet: 0.00 Plan Check# Plan#
Fees Amount Payments Amount Paid
Dishwasher $12.46 Total Fees $112.40
Electrical Permit Issuance Fee $44.35 Cash/Receipt#REC-000920-2018 $112.40
Light Fixtures $1.54
Amount Due: $0.00
Outlets-Receptacles&Switches $7.70
Plumbing Permit Issuance Fee $44.35
Solid Waste Management Fee 2 $1.00
Solid Waste Management Fee 2 $1.00
Total: $112.40
8 Z2—"/ CALLS FOR INSPECTIONS
Request for inspection by telephone at 626-574-5450. Leave a message
t requesting the address,timeframe and what inspection item is needed.
'Ft
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
aArcadia building inspector for a period of 180 consecutive days.
,lamttvw\stitl
April 19, 2018
Issued By: Date
April 19,2018 Page 1 of 1
o
014�FF `'9dr
117 PERMIT/PLAN REVIEW APPLICATION
o j` Development Services Department,240 West Huntington Drive,Post Office Box 60021
mm.o.„aw Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
0 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. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class License No. Exp. Date 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
OWNER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section
El 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
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
certify that in the performance of the work for which this permit is issued,I shall
exempt there from 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 of 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
El 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 l�
sale(Section 7044,Business and Professions Code:The Contractors License ate Y l" mature
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).
0 I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature 1 Lender's Address
INIPORTANT: 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 t disturbing the asbestos. Please contact AQMD at(909)396-2000 for
further information.
tame Ix e k d / itle •
tU/(,/
PRINT NAME
I certify that I have read this application and state that the above information is co ect 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 property for inspection purposes.
Signature 1Date & / 9 2 C.) 6
I
City of Arcadia, CA d Perm,tNo Misc 18 0001
11
Development Services Department `"` �x Permit Type Misc:=
(tem s� 240 West Huntington Drive,Post Office Box 60021
_' ,` Work'�Classification Real Estate Inspection
Arcadia,CA 91066-6021 i ,
(626)574 5416 �ai�r l e,'
.' ; Permit Status Issued
ARCI
Issue Date 02/20/291.8' Expiration:
Addr NO. Dir Prefix Street Name Street Suffix City,State,Zip Parcel Number
28 E Santa Anita TER Arcadia,CA 5781001033
Contacts
KIM,JAE K AND MIA Owner
28 E SANTA ANITA TER
Description: Valuation: S 0.00 Tenant
Total Sq Feet: 0.00 Plan Check it Plan It
Fees Amount payments Amount Paid
Building Issuing Fee $44.35 Total Fees $50.60
Solid Waste Management Fee $6.25 Cash/Receipt# $50.60
Total: $50.60 Amount Due:
$0.00
This permit/plan review expires by time limitation and becomes null and
epoil void if the work authorized by the permit is not commenced within 180 days
copipiETED from the date of plan submittal.This ermit ex ires and becomes null and
P P
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 days.
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 consecutive days.
February 20, 2018
Issued By: Date
k
February 20,2018 Page 1 of 2
Of Anc
G~4 "9�7
• "+! 1 PERMIT/PLAN REVIEW APPLICATION
o tV.jc Development Services Department,240 West Huntington.Drive,Post Office Box 60021
044.a,„ofw Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
0 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. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class License No. Exp. Date 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
OWNER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section
0 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
demolish,or repair any structure,prior to its issuance,also required the applicant
Policy Number
for such permit to file a signed statement that he or she is licensed pursuant to the (This section need not be completed if the permit is for one hundred dollars or less)
provisions of the Contractors License Law(Chapter 9(commencing with Section
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 1 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). 1 damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
0 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 k /?� Title
PRINT NAME
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.
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- entionec erty for inspection purposes.
Signature Date e—..,2---C) — .,,2_e/ j
! P •' OPERTY INSPECTION REPORT
ja\E4VP
eo
o„�8A2&9, Development Services Department, Building Services
240 West Huntington Drive, Post Office Box 60021,Arcadia, CA 91066-6021
City
of
(626) 574-5416, Fax (626) 447-9173
Arcadia
•
I, Tr'l 6 / , ownerof property located at
(please print n me) - -
d �" , Ita ,' -gyp y Arcadia, California, do hereby
(please pont ddress)
give my consent for a property inspection at the above address by the Development Services Department,
Building Services.
The purpose of the inspection is to investigate construction work which may have been done without the
benefit of City permits, approvals, or inspections. The undersigned agrees that all violations found by
the inspection will be corrected to comply with applicable City codes and ordinances within thirty (30)
days from the date of the inspection.
NOTE: This i5 not a permit and does not constitute acceptance of the work by the City. All identified
corrections must be completed prior to final approval of the work by the City.
INSPECTION REQUESTED FOR: 1.4r �. V.-Q-1 °/� _l 0/ "f
$ Pfef ! 5 r6
Date -- .d /1' Signed
Planning Services approval obtained: �=�' Yes U Not Required
Fire Department approval obtained: U Yes C4'` Not Required
Public Works Services, Water Section, approval obtained: ® Yes Not Required
BUILDING CORRECTIONS REQUIRED:
'U13M WAS /4,-1717gOVAL
Z. OP (11/4) $u!Uwll 4Gcg-1ChL, p flS
PERMITS REQUIRED:
P'4 Building U Demolition a Electrical U Mechanical ® Plumbing
INSPECTOR 4K,r INSPECTION DATE
FEE APPROVAL DATE
WHITE--File Copy YELLOW--Applicant Copy
•
JOB ADDRESS
r
a. r
NUMBkrc STREET
•
• APPLICATION FOR A
-' BUILDING PERMIT .
o ( BUILDING & SAFETY 'DIVISION
CITY OF ARCADIA, CCALIFORNIAVl
01OWNER4
6
�riifp-P -r�f 1.__J
I..! MAILADD ESS
CO ARCH. TEL. NO.
ENGR.
c-
C7 CONT CTOR STATE LIC.NO.
/�
MAILING ADDRESS d CITY LIC. NO.
. 01
CITY TEL. NO.
t.
v DESCRIPTION OF WORK
• NEW ❑ ADD'N 0 ALTER J REPAIR ❑ DEMOLISH 0
• FLOOR AREA NO. OF NO.OF DWELLING
(SQ.FT.) STORIES ,UNITS
PRESENT BLDG. USE PROPOSED BLDG.'USE
i ,
, U TO8EIBE f//K /444/ � // i .
0 /2-4,V-,Y.u.grat r
• .c,..
• NOTE: PROVIDE PLOT PLAN ON BACK SIDE OF,ORIG AL COPY ONLY '
EXTERIOR WALL MATERIAL ROOF FRAMING TERIAL
PARTITIONING MATERIAL ROOF COVERING MATERIAL
LOT LOT NO.OF EXISTING
WIDTH DEPTH BLDGS. ON LOT
NOTE: Include Labor, Mat., OO O 0
VALUATION wiring, Plumb., :teat, Etc. 1)_.4.
. INFORMATION PROVIDED BY BLDG. SECTION
• 2T.PT 1 ). BNO. TRACT
USE / FIRES OCCU- % SEC_ H
f
- ZONE / ZONE , , PANCY ��- SH. y
REO'D FRONT RIGHT SIDE LEFT SIDE REAR ac
SET p
- F BACKS _ v
TYPE OFR SPECIAL N^ I-
• CONSTR CASE NO.!KJ 'GRADE Z
0
Approval & Information by Whom . U
• CITY ENGINEER EASEMENT •
DIST. FACE OF SEWER DRIVE
CURB TO P. L. FT. AVAILABLE OVER
PUBLIC SERVICE PLANNING •PLAN CK.FEE
d
• WATER ELECTRIC V EE
PERMIT FEE
PLAN NO CHECKER'S APPROVAL I Q
E have carefully read and.exaoolned the above application and find tits
same to be true and cornet. All provision; of the Laws and Clifton's' TOTAL.FEE
' • - "governing building construction will be seorplied with whether sped. /.
fled heroin or•aot. No palms Shall ha employed in violation of tbo Later. /3.S(-0
Cods of tics pe Stats of California.I ase.not to occupy or allow occupancy • •
" , ; 'ef:any building autborizsd•by this pencil until final'building i lon•bas boon ;moire:
7 t 7Z,_ AO '
' • ' SIGNATURE OF OWNER OR'AUTHORIZED AGENT •
P NEN7
FORM B.51 (REV.741) 2'/iM 0. . .
4�OjuF RRn• y9d
Cj.i e• 9 PERMIT/PLAN REVIEW APPLICATION
;4'111\4.4a.
-"E Development Services Department,240 West Huntington Drive,Post Office Box 60021
\,„...„6,.
Arcadia, CA 91066-6021, (626) 574-5416,Fax(626) 447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
0 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. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class License No. Exp. Date 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
•
❑ I have and will maintain workers'compensation insurance,as required by Section
OWNER-BUILDER DECLARATION
0 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
demolish,or repair any structure,prior to its issuance,also required the applicant
Policy Number
for such permit to file a signed statement that he or she is licensed pursuant to the
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 0 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.
0 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).
0 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 Title
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 upon the above-mentioned property for inspection purposes.
Signature Date