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Home My WebLink AboutUntitled VEIL _ (AP use only) ACCOUNTS PAYABLE CHECK REQUEST Request Date 12/27/2019 Department DSD - Building Dept. Check Payable to MULIJONO LOCKMAN ffTYOP Address 20250 CARREY RD ARCADI . City,State,Zip Code WALNUT, CA 91789 INVOICE NUMBERS) (if applicable) ACCOUNT NUMBER(S) AMOUNT 714-2275 $ 1,990.00 5 S S $ TOTAL CHECK AMOUNT $ 1 ,990.00 Reason for Payment: Please refund the demolition bond to the above recipient. Permit: BOO-045-344 1143 PALOMA DR APPROVED BY(MUST BE SIGNED BY AUTHORIZED SIGNERS) Signature Date Approved 2nd SIGNATURE'REDUIREDFOR ANY.CHECK AMOUNrOVER$2,500 ; • - ,' . I• Signature Date Approved ACCOUNTS PAYABLE USE ONLY Check here if check is to be Ii Reviewer's Initials returned to Department VR112019 ". 'ia• Development Services Department ;, I.! 240 West Huntington Drive,Post Office Box 60021 ''---- ' Arcadia,CA 91066-6021 PERMIT NO: • BOO-045-344 City of (626) 574-5416,Fax(626)447-9173 Arcadia . Permit Type: Demolition PROJECT TRACT NO. LOT NO. APPLICATION DATE ISSUED BY PRINT DATE PERMIT STATUS 15928 12/122013 CM 8:57 4/6/2018 Issued ADDRESS NO. Dir.Prefix Street Name Street Suffix UNIT SLG ASSESSORS PARCEL NO. GEO CODE 1143 Paloma Dr 5776-004-008 OWNER MAIUNG ADDRESS PHONE NO. (909)594-7070 Inspector#: JOHN Mulijono Lockman 1143 Paloma Dr Arcadia,CA 91007 EMAIL ADDRESS: APPLICANT MAILING ADDRESS PHONE NO. Ortiz Demolition EMAIL ADDRESS: ' CONTRACTORIPROFESSIONAL MAILING ADDRESS Ortiz Demolition, Inc ' 145 S Archibald Avenue 1-1-31- PHONE NO. (213)216-4405 FAX NO. On o, CA 91761 EMAIL ADDRESS: License No. 902123 Type: C21 Expire . 8/31/2014 12:00: TENANT MAIUNG ADDRESS PHONE NO. . FAX NO. ; DESCRIPTION lel° fl , DEMO HOUSE AND 2-CAR DETACHED GARAGE IN PREP FOR SF/NEW RES. 'EF 1° ‘. i `/ Construction Type UOM IIof Units Velue Construction Type UOM �pl of Unita` �/� /.Values / • OCCUPANCY: TOTAL VALUATION: $0.00 QTY UOM DESC AMT AMT PAID ACCT QTY UOM DEMIT MIT PAID ACCT 1.00 Flat Pllnbg issuance 44.35 44.35 01-3105 1.00 eachSewer cap 14.35 15.55 01-3105 I Vnbit 1.00 FlatDemo issue 44.35 44.35 01-3107 1,990.00 sq a Demolition 77.78 77.78 22-3107 COMPLETED 1,990.00 sq fl Bond-demo 1,990.00 1,990.00 2275 1.00 Flat SWMF 2 1.00 1.00 88-3027 Total Fees: $2,173.03 Balance Due: $0.00 Paid Today: This permit/plan review expires by time limitation and becomes null and void if the work authorized by the Receipt : 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. 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) A. q;.,,.eoasy<• 1 PERMIT/PLAN REVIEW APPLICATION It idw,pm i 3, Development Services Department,240 West Huntington Drive,Post Office Box 60021 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 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 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 ❑ 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 employei to criminal penalties and civil fines up to one completion,the owner-builder will have the burden of proving that he or she hundred,tliousand 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 attomey'sfees.. ❑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 them 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: I. 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