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' VIUVD}IV . panssi sn.3o15s!wsd !.` 9TPS-VLS(9Z9) ) ietwapail8wgwn!d ,UogoJ(JISSa!J>!10 ,railer { 1E09-99016 V7'e!Peo>V euI wn adAl 1!w1ariu (� rrf c7 TZ009 xog wylp]Sod'anp0 uolBugunp 15aM on .q Id_ d ,, luawireda0 sao!n1aS wawdo!ana0 $ L690 6i-;11nld •oNuwJad v 'elpe»tl;o AID to y'. •FAR oraaroarv44,4 1111, I` PERMIT/PLAN REVIEW APPLICATION •4 ..r a�I jc Development Services Department,240 West Huntington Drive,Post Office Box 60021 m• <�° ,l,,, 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 d-3 License 'JDate' i a. compensation,mncwork for by Section is ss the Labor Code, for the 7/f/14/4-4...r 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 ❑ 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(w�or/ke 'compensation' _1- insurance carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier Teles Lake demolish,or repair any structure,prior to its issuance,also required the applicant i..-A6066)?-0i..-A6066)?-0for 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 Sections 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, forthwith comply with those provisions. or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for ��/��///��, sale(Section 7044,Business and Professions Code:The Contractors License k.Da_te tr 10— 1 Q Signature 7--e 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). ❑ I am exempt under Section 7044,Business and Professions Code,for this mason: 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 ( ame further information. kvtf pno,,,YIbOU, k„,aJvwt Tie\\ PRINT NAbm J I certify that I have read this application and state that the above information is co ct 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 boove-m,,.ti)•I:i r roperty for inspection purposes. ignatme - L (Date � p��0—� I'