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I •i City of Arcadia, CA Permit No RALT-18-1445 { •j Development Services Department PerrIDd Type I�eSidential Addition/Alteration I 240 West Huntington Drive,Post Office Box 60021 'I ).-.. , R t 1 if* [` i f[ .-1 f- Res-Addition/Alteration:: Arcadia,CA 91066-6021 -�er, {�,�1J 4,L.; 1,.,..+ .+„..+ _ :,rr- (626)574-5416 y ':- :4-:217'&13'.1.; ",�, ` 'ria+ ,Permit statw':Issded ARCADIA Issue Date os/13/2018 Expiration: 02/09/2019 Addr NO, Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1109 Encino AVE Arcadia,CA 5780014032III Contacts YAMADA,GARY A AND LILY B Owner CHRISTOPHER WILLIAMS* General Contractor(B) ' 1109 ENCINO AVE P.O.Box 8652,La Crescenta,CA 91224 (626)623-2659 (818)903-7053 Description:ADDITION TO CREATE NEW MASTER STE (BED Valuation:_ $206,925.00 . Tenant #4)FAMILY RM,OFFICE,LAUNDRY,POWDER RM,REMODEL KITCHEN,ENCLOSE FRONT PORCH TO CREATE NEW ENTRY Total Sq Feet: 1230.00 = Plan Check it Plan N 32572 s, Fees Amount Payments Amount Paid Building Issuing Fee $44.35 Total Fees $5,545.76 Building Permit Fees $1,962.30 Cash/Receipt tt REC-002001-2018 $5,545.76 Green Building Standard $9.00 Parks&Recreation Fee(SFR) $3,496.95 Amount Due: $0.00 Solid Waste Management Fee $6.25 Strong Motion Inst.Program Res $26.91 rrr'''''����1 CO1PLEi Total: $5,545.76 1- / I I� CALLS FOR INSPECTIONS Request for inspection by telephone at 626-574-5450. Leave a message requesting the address,timeframe and what inspection 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. Lam/AV August 13,2018 ���DDD Issued By: Date August 13,2018 Page 1 of 1 .FA• ,,ovoitvNi a • 1 PERMIT/PLAN REVIEW APPLICATION s. 6* i' 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 d Professions Cod nd 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 License No?��3� Exp. Dated �� 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 wo for which this permit License Law for the following reason(Section 7031.5,Business and Professions is issued.My ynrkers'tcompensatio ace catrie d policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, . Carrier �1C� demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number ( cr 3 2_02_0837--0� � l 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 do]ars 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 0 I 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 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 c ply those provisions. compensation,will do the work,and the structure is not intended or offered for p sale(Section 7044,Business and Professions Code:The Contractors License Date___ C 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(I)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: 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. (Nathe .t_ s \ 4 Title D LA—er PRINT N• E 41 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 .'th all Ci ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of 1f\Arcadia to enter 'on I • . . • , • ,u, •property for inspection purposes. ////� //,/f signature Date g G 1 ' ` 6 .. • . NOTES Building Inspections Date Insp. - Plumbing Inspections Date Insp. 1 1®T •fesv0 tJ 0 /�-1 _, 100. Setbacks 210. Under fib/bldg.drain f,-/1 4 n. - lsr��' sa 101. Rough grade 211. Copper underslab l 102. Figs.&forms f 3-(q 212. Rough plumbing 103. Pre-slab 213. Rough gas 4 -ei 104. Floor joists J1-Ifr18 214. Shower pan 7-(V99 123-18lwle46r o gad 105. Steel 215. Water heater / l)Dit'( ?ki 4 r 106. Grout lift ,�,•, 216. Roof drains ¢ 107. Shear nailing 6-10-ci 'r W 217. Building sewer .1 -IS" '1 I44 " t�[lbir( 108. Diaph nailing 218. Water service `riiir74 , vcreghtdcky mi 109. nailing 3�,,•{1 t'y�.I 219. Final gas -19.1' ' „Hit rroDg c OlGT e Fo 110. Framing (�p-Lt V W 220. Fixtures L�I r"' 111. OcciArea Sept.Wall 221. Final plumbing trit4-t1 .Iry 6.SCVA4JGE 6L4 112. Sound walls 222. Sewer cap/demo. 113. T-bar.rid 114. Insulation-Flo ( .- : .'\ Pool Inspections Date Insp. 115. Insulation-Wall 41/4- 240. Excavation/steel 116. Insulation-Ceil. 6<r-' 241. Rough plumbing 117. Drywall nailing 647-4 , ` 242. Light shell/bonding 118. Interior lath ZZ j '-t [it 243. Underground conduit 119. Exterior lath 1`j-{Q-(4 *-741 244. P-trap -- - 120. Finish grade1 245. Gas line&test 121. Final building j/4S1 1 R , 246. Fence,gates&signs 122. Final demo/lot clear 247. Pool heater 248. Final electric Electrical Inspections Date InsP• 249. Final.lumbin. 150. Power pole 250. Pool cover 151. Sales lot lighting 251. Pool final 152. Unde 'round conduit 153. Underslab conduit Reroof Inspections I Date I Insp. 154. UFER ground 270. Pre-reroof insp. 155. Water ground �\ 271. Roof framing 156. Rough electrical 41±1% Y- _ 272. Sheathing nailing - 157. Fudures 273. Final reroof 158. G.F.C.I. 159. E..t.bondin. w Sign Inspections I Date Insp. 160. Service panel ;.)3-Ie t2 280. Setback/overhang 161. Final electric /143-14281. Footing 282. Conduitwirin. Mechanical Inspections Date Insp.. 283. Disconnect 180. Venting/flue 284. Final sign 181. Furnace/A.C. � 182. Rauch HVAC ' Miscellaneous Insp. Date 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. Commerdal hood 190. Duct shaft Sewers&Offsite Insp. I Date Insp. 191. Final mechanical (es :.4' 91 300. Lateral(main to PIL) 301. Saddler? Block Wall Inspections ' Date Insp. 302. Cess...I filled 200. Footings 303. Sidewalk 201. SteeVrebar 304. Driveway 202. Grout lift 305. Curb replacement 203. Final wall 306. Trash bin Certificate No.20121023-892 ARCADIA UNIFIED SCHOOL DISTRICT 150 South Third Avenue, Arcadia, CA 91006 • (626) 821-8300 Ext. 6732 Certificate of Compliance for Payment of Developer Fees (Education Code117620,et seq. &Government Code §65995,et seq.) Effective July 24,2017 Current rate in effect applies at the time of imposition of fees/payment. Project Address/APN: 1109 Encino Ave. , Arcadia, CA 91006 Number of Units in Project: One Plan Check Number: 17-410 [ l* [X ti,* [ J*::: Exempt: [ ]500 sq.ft.or less(residential addition/expansion/remodel) Residential Commercial/Industrial [ ]Other: $3.20/sq.ft. $0.51/sq. ft. Area in Sq.Ft.: 1 , 230 Receipt Number: 330413 Total Fee: Check Number: 1157423296 $3, 936 . 00 Owner's Name: Lily Yamada Owner's Address: 1109 Encino Ave. , Arcadia, CA 91006 Phone Number: 626-623-2659 Email: lilyyamada@outlook. com Representative's Name& Contact Info (if appl.): *The above-described development has been determined to be exempt from the developer fees of Education Code§17620,et seq., and Government Code§65995,a seq.,and a Building Permit may be issued therefore. ** All fees due to the Arcadia Unified School District, under provision of Education Code §17620, et seq., and Government Code §65995, et seq., as a prerequisite to the issuance of a Building Permit by the Building Department of the City of Arcadia, City of Monrovia,City of Sierra Madre,City of Temple City,and County of Los Angeles,Department of Public Works have been received. Based on the i i ormation prese -d above,this Certificate of Compliance is hereby executed. Connie Chu / fir i Senior Administrative Asst . 8/7/18 Signature of District Representative Name/Title Date of Issuance D The District charges a $100 fee to process reinstatement of the Developer Fee Certificate of Compliance resulting from an "insufficient funds"check in addition to a$35 fee for the returned check. Only cash or a Cashier's Check will be accepted as payment thereafter. D The District charges a$100 fee for any amendments to or cancellation of a Developer Fee Certificate of Compliance formerly issued on any type of development. D If 500 sq. ft. or less is the reason for exemption,any future additions,expansions,or remodels to the property that result in the past aggregate square footage to exceed the allotted 500 sq. ft. will be subject to fees at the current rate for the entire square footage of the development. D Owner/developer may request a refund of fees paid to the District within 12 months of payment only in the event the Building Permit expires or the project is canceled without commencement of construction in accordance with Education Code section 17624(all other requests for refunds must be made in accordance with the fee protest procedures set forth in Government Code §66020). All refunds will be reduced by a $100 administrative fee. The refund check will be issued in the name of the owner/developer and mailed to the address of payee. PURSUANT TO GOVERNMENT CODE§66020(d), OWNER/DEVELOPER HAS A PERIOD OF 90 DAYS FROM THE DATE OF ISSUANCE OF THIS CERTIFICATE OF COMPLIANCE TO PROTEST THE IMPOSITION OF FEES Applicant confirms that he/she is authorized to sign on behalf of the owner/developer and that the information he/she provided to the District is true and accurate to the best of his/her knowledge. `/ Signature of Applicant: �' N Name: I 1 a waktAi WHITE-City/County YELLOW-Fiscal Services PINK-Business Services GOLD-Applicant Certificate of Compliance(7-24-17) ` 94.35 --' ------ JTr ¢� I ---------A �'." EKP&.PLI,Pp0.BARRIER I.TS' � — �__k__ --_AO - (BO'XI6X7 WlOPc=NFf OF ©g B]Y. 5% _____. (X 19.35 A —_ © GGONNG.DECK _— I6O� 30'-0' _ _ _——4F 41.6• T•-B- __ 0 _ — { __ (E) POOL — - mwluml-. Si EXTK &ATE(6C X4510 W W k % sip -AtO WLP-LAT09N6 C• DEV15E/56• - /Jm 51EX'PO01. 1315' L AREA KEEP GATE •--• v o� silk -- -- •• a 3.A— --- 4 •• A - V� AG --T� n Iii ` x A .; PROPOSED ` � . uO� Y o ADDITION �o0 0 9» ' a• p S1L k 1 d• I '.^4.-641_ Obi aL --- ----- -- - fi X liA1Fl l lyy V 0o n 1—STORY S.F.D o., i _ till ii, — slams0 1:•-0• 91'•6• l0'-4' t-0•? egxr'e. oo A - • PROPOSED �ro _Ezra-- GAL `� 1•HR ROOP 414 liISERVIG --_—_^ -A-DDITI�N ceraiu AD1. LL I A. :_,:v_.,.:,,_v. _- 12 4 J— e1 WD FATF I = - © ---- CJ _ I 15.10 I -- 44•B "} A (E) FRONT YARD TO REMAIN I a7� SAND BAS BARRIER,TYP. _ ��' aNlieTCr ���SA1����_1al a1_i_ .O—" P 0 - \ PARKWAY ENCINO AVE iioa ENCMIO ITI NOTE: 51 TE PLAN Au. NWGoursnNc. NO Ec�NPROPOSED. WALE.1/6••1'-0' City of Arcadia, CA -. ' Permit NO. MEP-19-2324 Z Development Services Department Permit Type:MEP 240 West Huntington Drive,Pos[Office Bax 60021 1 eft '-- 1 �� , C�(Arcadia,CA 91066-6021 'I-JF \L.-5 , Liu Work Classification:MEP-Residential (626)574-5416 Permit StotuS.'ISslled ARCADIA Issue Date:11/15/2019., Expiration: Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1109 ENCINO AVE Arcadia,CA 91006-4447 5780014032 Contacts YAMADA,GARY A AND LILY B Owner 1109 ENCINO AVE (626)623-2659 Description:MEP FOR ADDITION AND REMODEL. 200 AMP Valuation: $ 0.00 ' Tenant SERVICE.HVAC SYSTEM PER APPROVED PLANS. HERS REQUIRED FOR FINAL. Total Sq Feet: 0.00 Plan Check It Plan k Fees Amount Payments Amount Paid Bar Sink $13.21 Total Fees $650.26 Clothes Washer $13.21 Cash/Receipt U REC-03108-19 $650.26 Compressor 3-5 Ton(3 to 15 hp) $36.35 Dishwasher $13.21 Amount Due: $0.00 Electrical Permit Issuance Fee $47.01 CONP[E1ED Furnace or Burner 100,000 BTU $19.86 Garbage Disposal Fee $13.21 Gas System(Outlets) $15.55 Hood Serviced by Mechanical Exhaust $14.96 Kitchen Sink $13.21 Lavatories $79.26 CALLS FOR INSPECTIONS Mechanical Permit Issuance Fee $47.01 Request for inspection by telephone at 626-574-5450. Leave a message New Residential Elect.(sq ft area) $100.00 requesting the address,timeframe and what inspection item is needed. Plumbing Permit Issuance Fee $47.01 Residential Services up to 400 amps $16.48 Shower $39.63 This permit/plan review expires by time limitation and becomes null and Solid Waste Management Fee 2 $1.00 void If the work authorized by the permit is not commenced within 180 days Solid Waste Management Fee 2 $1.00 from the date of issuance or if the permit is not obtained within 180 days Solid Waste Management Fee 2 $1.00 from the date of plan submittal.This permit expires and becomes null and Ventilation Fan(Single Duct) S49.70 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 Water Closet $52.84 Arcadia building inspector for a period of 180 consecutive days. Total: $650.26 fri4i.. 64 le November 15,2019 Issued By: Date November 15,2019 Page 1 of 1 a,}FO$vr,.• Ski PERMIT/PLAN REVIEW APPLICATION SxI. Etc �f :v„„r %.1:15347.741'. 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 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 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 ('' 's 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 "F exempt there from and the basis for the alleged exemption. Any violation of u j certdy that in the performance of the work for which this permit is issued,I shall Section 70315 by any applicant for a permit subjects the applicant to a civil I 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 porkers'compensation provisions of Section 3700 of the Labor Code,I shall 0 I, as owner of the property, forthwith comply with those provisions. or and employees is withtwagesnas theirs for /� /� compensation,will do the work, the structure not intended or offered for :,Dta l l (�1(a Signature {U/.y-•pr-t.�`tic sale(Section 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon, I) 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 Lender's Address ate U 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 f1 further information. (� � 9 _ JJ F� V Ul L26w101 0.V1-o-9t.P- Ttle DO'lrre& u-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 upon the above-mentioned property for inspection purposes. I I p Signature l/�Jln LA_O �� ate' IL f l [ I 1 �_/U` l �/II�_�1_ tioroes' City of Arcadia, CA Permit NO. RALT-18-1445 tip Development Services Department Igk:c;? r ype Residential Addition/Alteration 1y{/ 240 West Huntington Drive,Past Off ce Boz 60021IWolkdassrf cpnon:Res-Addition/Alteration `ti� vArcadia,CA 91066-6021 t � (626)574-5416 Permit StdturExpired ARCADIA - Issue-pate:08/13/2018 1 Expiration: 02/09/2019 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1109 Encino AVE Arcadia,CA 5780014032 Contacts YAMADA,GARY A AND LILY B Owner CHRISTOPHER WILLIAMS* General Contractor(B) 1109 ENCINO AVE P.O.Box 8652,La Crescenta,CA 91224 (626)623-2659 (818)903-7053 711380 Description:ADDITION TO CREATE NEW MASTER STE (BED Valuation: $ 206,925.00 Tenant #4)FAMILY RM,OFFICE,LAUNDRY,POWDER RM,REMODEL KITCHEN,ENCLOSE FRONT PORCH TO CREATE NEW ENTRY. Total Sq Feet: 1,230.00 Plan Check ff Plan N 32572 ••AMENDED 5-17-19 ADD 3 SKYLIGHTS** Fees Amount Payments Amount Paid Building Issuing Fee $44.35 Total Fees $5,545.76 Building Permit Fees $1,962.30 Cash/Receipt tt REC-002001-2018 $5,545.76 Green Building Standard $9.00 Parks&Recreation Fee(SFR) $3,496.95 Amount Due: $0.00 Solid Waste Management Fee $6.25 Strong Motion Inst.Program Res $26.91 Total: $5,545.76 I''13 d et COIffPjij8OR INSPECTIONS 1'�{�( -t / WRequest for inspection byte . t 626-574-5450. Leave a message .( Sv requesting the address,timeframe and what inspection item is needed. 1 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. August 13,2018 Issued By: Date May 17,2019 Page 1 of 1 ,FAft 4 u I PERMIT/PLAN REVIEW APPLICATION `t4 l 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. 0 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 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 CII 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 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 CdOba' Permit No Elec-19-0259 � City of Arcadia, CA ���---. .`- - t 111'7 Development Services Department � f'r'y Permit Type:Electrical 240 West Huntington Drive,Post Office Box 60021 4�(��(IW{ X ' Arcadia,CA 91066-6021 k Classification:Elec-Temporary Power Pole —n (626)574-5416 - - Permit Status:Issued ARCADIA Issue Date:02/07/2019 I Expiration: 08/06/2019 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1109 Encino AVE Arcadia,CA 5780014032 Contacts YAMADA,GARY A AND LILY B Owner Andy Gump,Inc. Contractor 1109 ENCINO AVE 26954 Ruether,Santa Clarita,CA 91351 (626)623-2659 (661)251-7721 357789 Description:T.P.P.FOR SFR/NEW Valuation: $ 0.00 Tenant Total Sq Feet: 0.00 Plan Check# Plan# Fees Amount Payments Amount Paid Electrical Permit Issuance Fee $47.01 Total Fees $81.40 Solid Waste Management Fee 2 $1.00 Cash/Receipt#REC-00343-19 $81.40 Temp Power Pole(auto) $33.39 Amount Due: $0.00 Total: $81.40 2-8--1611 ✓ COMPLETED pie * /kL 414 CALLS FOR INSPECTIONS Request for inspection by telephone at 626-574-5450. Leave a message requesting the address,timeframe and what inspection 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. r .‘) February 07,2019 Issue y: Date February 07,2019 Page 1 of 1 , AR . 0,,,yroyyy<i --r - l 4 ,.., 1; PERMIT/PLAN REVIEW APPLICATION iiii: .4•4 to Development Services Department,240 West Huntington Drive,Post Office Box 60021 ,\ _,,,„fl Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173 City of Arcadia iiihro ICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION ereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following: hapter 9(commencing with Section 7000,of Division 3 of the Business and fessions 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 L'-f f' License No. ....35-77S ,p.Date Y' "0 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 ave 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 insumnfe carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier A 1-46 K 6 _ i P ' _ demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number O f`') n (-C✓ 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 70315 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 �p - — sale(Section 7044,Business and Professions Code:The Contractors License te 7- r Signature J—�`� 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 attomey'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. ,('}� N e LIQ 9 b2ti / Title ti- ' 32' PC--L GCS 13 PRINT NAME I rtify 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 ti to enter upon the above-mentioned property for inspection purposes. ignature Date �7 q ,tom - -\ Headquarters Mailing Address aRental.Agreement Andy Gump Inc. AflUy]' un ts G118544 Santa Clarita, CA, 91351 TEMPORARYITE SERVICES 800-992-7755 FAX(661)251-7729 Order www.andygump.com 1-800-992-7755 Contract No. G116544 Job No. Location Code SC-TP B01 To: C18370 Ship To: Job Type: RC CHRIS WILLIAMS 1109 ENCINO AVE Egmt Type 7P P.O.BOX 8652 ARCADIA,91006 Map Page LA567-E7 LA CRESCENTA,91224 CA Tract No. CA United States Lot No. United States Billing Phone No. 818-903-7053 Geo Code 34.1279773,-118.0174651 Phone No. 818-903-7053 Cross Street CAMINO GROVE AVE Cell Phone No. Job Collect ALFREDO ISLAS Job Phone No. 323-479-3624 Job Cell No. 323-479-3624 Job Access COMBO(32 10 20) Order By Purchase Order No. Terms Andy Gump Rep Order Taken By Date CHRIS WILLIAMS ON RECEIPT GEORGIE AGIGEORGIE 1/30/2019 3:03 PM 818-903-7053 661-977-3853 Item No. I QTY tDescription Start Date End Date Days Billed l Amount Line Amount , 100-0100 1 1 1100A OH SCE MAIN RENT _ 2/7/19 4/3/19 56 J $5s.soj 5119.00 110-0001 _ 1 I TEMP POWER IN&OUT $595.00' $595.00: 120-0001 1 1AG FEE TO OBTAIN PERMIT $150.00 5150.001 120-0002 1_TEMP POWER PERMIT FEE-ESTIMATED $76.40 . $76.401 110-0006 1 TEMP POWER HAND DIG IN $75.00 $7500 110-0007 1TEMP POWER HAND REMOVAL $75.00 575.00 110-FUEL I 1 I TEMP POWER FUEL SURCHARGE $25.00 525.001 PLEASE CALL FOR PICK UP OF EQUIPMENT.METER MUST BE DE-ENERGIZED BY SCE PRIOR TO subtotal $1,115.40 REMOVAL OF MAIN Damage Waiver $0.00 Tax 50.00 Payment $ Ck# Cash Credit Card Approval# Total $1;115.40 Service Instructions - - ;2-7- 9(;HURS)INSTALL(11100.,.OH EDISON MAIN.AREAMARKED IN BKYD.NANDDIG/CA Qt1 gE UIRED.SEE ALFREDO ISLAS ON SITE,CALL W/1 HR ETA 323.479: 1362 ANDY GUMP'I. ULLL' ERMIT'PMT#RALT191445)CUSTICOjTAKEI,C?;IREOFIEDISO&TMEt J((DIG ALERT#A190300976 EXP 2-27-19"'G - Date Time In Time Out Work Performed QTY Equipment Equipment Unit Numbers. Driver/Helper Charge BILLING:Monthly bill is based.on 28 day billing cycle.Health code regulations require weedy service of portable restrooms. Andy Gump portable restroom service and or pumping labor are provided at the option of the lessee:CONTRACT ACCEPTANCE:I AGREE TO THE CONTRACT,INCLUDING TERMS AND CONDITIONS ON THE BACK OF THIS AGREEMENT. I ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT. Customer Service Signature Driver Pdntad Name IDate Wed !INVOICE0 !INVOICE AMOUNT !BY I wary Cid of Aicadh3 1„ or-070 241i%UrHanun CQUDlrve �fl.�CTRICA�i. M�CL�JAf�19CAL `PLUIVIRI 1(a . Ait.i iia Cr1 91J)116 0021. - , -:r A ' ?_ �ERfViI�- i_., i S9i��P • 4109.ENCINO,AVENUt t* I } • • BUILDING ADDRESS } ? Y • °.r '� d r t . It i IN8TALIL TEMP'POWERIPOLE}'"'`L +1' .�'+ ,BLp PMT#RALT1S7445 ' OESCRIPNDN OFyVOflK I z -2;-; I..- t -. SOUARE FEET TYPEOl CONSTgUCTION _a -' -y+ r e --- «VA�TIDN _ '3' GARY YAMATA _ —3r z 3 - I `1 r 62616'3 2659 OWNER NAIIE - " ` - •% `v ra,. —+— + -- - 4ONE - - - 1109,ENCINO AVENUE '` �' ''- 3 '' ' ` r z ,-s r - - . '7! ,tom r a CI7Y ARCAO-;�`-L•,_._.c.�.s. STATE kL. ZIP:91.0 D6 APPUCANTNAA?E -LEO OSORNIA 1 ' , '- x ,.., ' ,_.�.,:"'' ' --'PHONE.-661 510;1420• ' ADDRESS 26954 RUETHER AVE:, rTl _SANTA CLARITA• sTATe •CA zip 91351 r , r , CONTRACTOR .;ANDY GUMP INC .f .PHONE'--661.310.2146 ' .ADDRESS 26954 RUETHER AVE - ':,.r cny SANTA CL`ARITA +'-'s7At rA ZIP 91R6t • STATELIGENSE NDS 357789_ - LICENSECLAssi CID--- CPIRATION`DATE9/31)/193CrTY;LICENSEN0,,099R11 - ELECTflICALSYS7Erd - - ' '' r - ;J PLUMBING.dYsTEM r ' _J ` 11 cJ Units Description - (Atldllea;Commerelal Ilnduslr(al) - 0 ol,Unlsa IDescrlprldp 1 :,: . - , • Temporary Power:Pole: ':K ol.Pan&lsi"' v _ 'I } £ `P;24j-fifties-L._ - _ Balhmbs _. � _ 9oivic�s I c _. Showers .5L bullats`rieeaSues`iSwllches) +s 1 i 4. 1 I I { �-:.( • Tr .y I .L �Waler Chs r ` �Molcrs r -L N _•HP E eh L -' 1 x- ' r F u • • I _".- A " il :. , __<�sl�n Brarsdl Chc . ! .�. •r _.._..� i r ..:i•s fKllifienl5lnks • .. i - r--- - - . 'Pool Whng _ - - 11; � —.. I- ..-...4 _ - rDishx�sfior3 Sa:FI.Area Heir:Ret BUB ' S9 FL Rea NeW Res -4' -".� Garbage Disposals _ 'Acccaso.yeldg. s ��r , + -. tFloarstnk. MECHANICAL SYSTEM ' r ' , ) lFloarOmin tL ' ' 'ti i 11 o1:Unllsr DeSeflpllan it ,;(11;:!..' t J ?J , R t)v 5 • (Laundr tTrayZs F▪ 1 j . .I • _ .� - t - r 1:12, -i;tt rC(olheslYVashers .) { �: •—::[,.i":1,.%£.t�i f..:r lVi:.t ,4 T 1 1 t _� r ^.l Flao:/WaB/SUSP,/Haalar -._• .i ' ti I Pra•Eab Flreplarxrjalse4( +s �:?�_ z y � � '7747Z-7;_77 .Gas.S07ms d oullels-�s Kdctien Ven116Lnn------Ind—,uiL.. t ) c s -? Showar Pan R'eplecemenl icL -' ' Fun ng Uucl cCOMand 1ND only}. ;. y s r - a . :r r' _roc i _,u'...t o it L t j .r I .?SvJmmWg Pocl Plping ._.P usp _ • Bbacr/Camores;e'nh.endlndudlna�3HPr _, z - �+ _ , r I .. .. .;,,BollerI pies sorover,3HPdo;75HP ,a:.. .:(.,_.. 3 __: r--- '-.Pool WAIcr.Healer . =-7L .._:r. . __ y r _} T +ra ir_, 'S#.. F L Ci iBofer/Comprossoi over.I5HP.Ia 30HP_ ,..:2:<..:�.. " !..,..._,�-i : 1.Wnler'He"altir r ..._..�._4_,:, ... IBodeFiComPressoro'ver30HPiii',SOHP kr,7r' 5 It ..: 1.I' 'f ktr:' u.4" v T"` r ' u - 1 rsprlsrConnedlons SdBcrlCompm sorovor SOHP Io 1 75HP , n r s-1 _r - ., r ' rl s d t7 l sp i ' ' + . 7•' s:.a > '-" .c 11�,wn SpilnNler SY91em Alr`HS. ttt to ondin'dudingil0000 OFH L.: t t i r -"{ 1 -• -- ' '_.AIr Hui lero'v-ri0000CFrd•_ •__ _ Mlscellaneaus _ z. .. Edepoiallve Coelcrz?: .f - `` . r: 10/08/08-- -- _. r 4.. ._ < t.....e..�:., - .:,r_•.. :. :- _ " _. . - Permit ROOF 9 0430 �, • City• of ent Aunt ngtionsDrrcadia, ivvea Post Office Box 60021 rtment D �� Werk C)ossffrot on:Re -tResidential' �,x�.-+o�d, Arcadia,CA 91066-6021 - . • T w l (626)574-5416 ' -'_ _ Permit'Status:Issued ARCADIA - _ a Issue:6ate:03/05/2019' Expiration: 09/01/2019 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1109 Encino AVE Arcadia,CA 5780014032 Contacts YAMADA,GARY A AND LILY B Owner P H ROOFING' Contractor 1109 ENCINO AVE 741 BELLEVIEW AVE,SAN DIMAS,CA 9177 (626)623-2659 (626)253-1942 Description:T.O,NEW SHEATHING.REROOF HOUSE/GARAGE Valuation: $ 18,900.00 Tenant WITH CERTAIN TEED LIFETIME PRESIDENTIAL CHARCOAL CLASS A 37 SQ.(LT) Total sq Feet: 0.00 Plan Check# Plan# Fees Amount Payments Amount Paid Building Issuing Fee $47.01 Total Fees $440.81 Building Permit Fees $387.55 Cash/Receipt#REC-00556-19 $440.81 Solid Waste Management Fee $6.25 Amount Due: $0.00 Total: $440.81 a re llktalki 4. 64 1411COPLmO 3 _I gr_(L} CALLS FOR INSPECTIONS CI Request for inspection by telephone at 626-574-5450. Leave a message FI.IV 1ic - vt�L requesting the address,timeframe and what inspection 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. q" March 05,2019 Issued By: Date March 05,2019 Page 1 of 1 . AR ,.`s� PERMIT/PLAN REVIEW APPLICATION iv au rip zila' 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 ClassC.- J h License No O3t7 t9 Exp. Date compensation, as provided for by Section 3700 of the Labor Code, for the DIJ performance of the work for which this permit is issued. 13 Signature of Contractor f 0 0/ WNER-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 mason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers am: Code.Any city or county which requires a permit to construct,alter,improve, Carrier 544 it Aqot trli demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number el011%S�6 for such pennit 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 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, forthwith comply with those provisions. or my employees with wages as their sole s compensation,will do the work,and the structure is not intended or offered for )-y'• sale(Section 7044,Business and Professions Code:The Contractors License Date _1 Signature ta"0 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 CONSTRUCTION LENDING AGENCY Code:The Contractors License Law does not apply to an owner of property 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.''rr arae T'�t'�,� C�4Pf:S Title Q 411"le I- PRiNT NAME certify that I have read this application and state that the above information is orrect and that I am the owner or duly authorized agent of the owner. (4 I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of Arcadia tooeenter upon the above-mentioned property for inspection purposes. U J ignature CkAA Date -Tr 5 ' r-I "-IS\ STRUCTURAL OBSERVATION REPORT FORM STRUCTURAL OBSERVATION means the visual observation of the structural system, for general conformance to the approved plans and specifications, at significant construction stages and at completion of the structural system. Structural observation does not include or waive the responsibility for the inspections required by Section 108, 1701 or other sections of the code. Report Na 03 This report includes all construction work through 25th day of March , 20 19 Page No. 1 of? Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1109 Encino Avenue,Arcadia, CA 91006 Thang Le, SE (626) 731-1539 Building Permit No.: Structural Observation performed by: Professional Lic./Reg.No.of Observer. Phone No.of Observer. Thang Le, SE S 4978 (626) 731-1539 OBSERVED STRUCTURAL ELEMENTS AND THEIR CONNECTIONS FOUNDATION ' WALL FRAMES ROOF/FLOOR ELEMENTS/CONNECTION OBSERVATION LOCATION ❑ Footing,Stem Walls, 0 Concrete 0 Steel Moment Frame ❑Concrete ❑ Mat Foundation ❑Masonry ❑Steel Braced Frame 0 Steel Deck 0 Caisson, Piles, Grade ill Wood ❑Concrete Moment Vi Wood Wall, floor and roof Beams Frame framing;sheathing nailing and hardware. 0 Retaining Foundation 0 Others: ❑Masonry Wall Frame ❑Others: Hillside Special Anchors ❑Others: ❑ Others: NOTED DEFICIENCIES with the proposed corresponding corrective actions with respect to general conformance with the approved plans or in the load path: (A final report by the structural observer which states that all observed deficiencies have been resolved is required before acceptance of the work by the building officials.) None. Okay to cover. • I DECLARE THAT THE FOLLOWING STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE: E IN PONSIBLE '. I AM THE CHARGE FOR HEST STRUCTURAL ERVATIONIINACCOR AOR ARCHITECT RETAINED BY THE CCORDANCE HER TO TTHER REQUIREMENTS /Qet 14.L 04 r OF THE CITY OF ARCADIA. Q e. ,, S 2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UN' R /n _'t A t MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT -•CH 1°- SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GENERAL r di Q y 2 CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; IMP'. �� 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED 4'* sr 30' \34 ABOVE; STATE OF 4. I RECOMMEND THAT ACCEPTANCE OF THE �UIRBAL SYSTEMS BY THE CITY OF - ARCADIA BE WITHHELD UNTIL ALL OBSE E EFI CIES ARE CORRECTED. 03(24/II SIGNATURE OF STRUCTURAL OBSERVER DATE STAMP OF STRUCTURAL OBSERVER) IN/Forn.08(Part 1)(Rev.1/12007) vnrx.ladles.org y �m I ill AR STRUCTURAL OBSERVATION REPORT FORM STRUCTURAL OBSERVATION means the visual observation of the structural system,-for general conformance to the approved plans and specifications, at significant construction stages and at completion of the structural system. Structural observation does not include or waive the responsibility for the inspections required by Section 108, 1701 or other sections of the code. Report No. 03 This report includes all construction work through 25th day of March , 20 19 Page No. 1 of? Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1109 Encino Avenue,Arcadia, CA 91006 Thang Le, SE (626) 731-1539 Building Permit No.: Structural Observation performed by: Professional Lic./Reg.No.of Observer: Phone No.of Observer. Thang Le, SE S 4978 (626) 731-1539 OBSERVED STRUCTURAL ELEMENTS AND THEIR CONNECTIONS FOUNDATION WALL FRAMES ROOF/FLOOR ELEMENTS/CONNECTION OBSERVATION LOCATION ❑ Footing, Stem Walls, 0 Concrete 0 Steel Moment Frame ❑Concrete ❑ Mat Foundation 0 Masonry 0 Steel Braced Frame 0 Steel Deck 0 Caisson, Piles, Grade VI Wood 0 Concrete Moment Wood Wall,floor and roof Beams Frame framing; sheathing nailing and hardware. ❑ Retaining Foundation ❑Others: ❑Masonry Wall Frame ❑Others: Hillside Special Anchors ❑Others: 0 Others: NOTED DEFICIENCIES with the proposed corresponding corrective actions with respect to general conformance with the approved plans or in the load path: (A final report by the structural observer which states that all observed deficiencies have been resolved is required before acceptance of the work by the building officials.) None. Okay to cover. I DECLARE THAT THE FOLLOWING STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE: 1. I AM THE ENGINEER OR ARCHITECT RETAINED BY THE OWNER TO BE IN RESPONSIBLE O(rESSION4. CHARGE FOR THESTRUCTURAL OBSERVATION IN ACCORDANCE WITH THE REQUIREMENTS Q�PNG fI. �FCZ OF THE CITY OF ARCADIA. • 2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UND• - W /+ MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT E CH CO -4979 SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GEN RAL FXp p513OI20 CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; Q. 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATEDtroS�6 OQ� ABOVE; sr li," �� 4. I RECOMMEND THAT ACCEPTANCE OF THE STRUC RAL SYSTEMS BY THE CITY OF qTE OF CPQ ARCADIA BE WITHHELD UNTIL ALL OBSERVE Fl ENCIES ARE CORRECTED. SIGNATURE OF STRUCTURAL OBSERVER / OATleS1 STAMP OF STRUCTURAL OBSERVER) INIForm.08(Part 1)(Rev.1112007) www.ladbs.org � I ARGyprm STRUCTURAL OBSERVATION REPORT FORM STRUCTURAL OBSERVATION means the visual observation of the structural system,for general conformance to the approved plans and specifications,at significant construction stages and at completion of the structural system. Structural observation does not include or waive the responsibility for the inspections required by Section 108, 1701 or other sections of the code. Report No. 02 This report includes all construction work through 4th day of March , 20 19 Page No. 1 of 1 Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1109 Encino Avenue,Arcadia, CA 91006 Thang Le, SE (626) 731-1539 Building Permit No.: Structural Observation performed by: Professional Lic.IReg.No.of Observer Phone No.of Observer: Thang Le, SE S 4978 (626) 731-1539 OBSERVED STRUCTURAL ELEMENTS AND THEIR CONNECTIONS FOUNDATION WALL FRAMES ROOF/FLOOR ELEMENTS/CONNECTION OBSERVATION LOCATION ❑ Footing, Stem Walls, ❑Concrete 0 Steel Moment Frame ❑Concrete 0 Mat Foundation 0 Masonry 0 Steel Braced Frame 0 Steel Deck ❑Caisson, Piles,Grade VI Wood 0 Concrete Moment 171 Wood Wall,floor and roof Beams Frame framing;sheathing nailing and hardware. ❑ Retaining Foundation 0 Others: 0 Masonry Wall Frame 0 Others: Hillside Special Anchors ❑Others: 0 Others: NOTED DEFICIENCIES with the proposed corresponding corrective actions with respect to general conformance with the approved plans or in the load path: (A final report by the structural observer which states that all observed deficiencies have been resolved is required before acceptance of the work by the building officials.) None. Okay to cover. I DECLARE THAT THE FOLLOWING STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE: 1. I AM THE ENGINEER OR ARCHITECT RETAINED BY THE OWNER TO BE IN RESPONSIBLE OFESSfON CHARGE FOR THE STRUCTURALOBSERVATION IN ACCORDANCE WITH THE REQUIREMENTS �� � F Cry G y � OF THE CITY OF ARCADIA. 2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UNDER MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT EACH w S • m SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GENERAL O[, '. 06131"1 CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; , 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED j S ABOVE; 1, .OF CA F(" V" 4. I RECOMMEND THAT ACCEPTANCE OF THE STRUCTURAL SYSTEMS BY THE CITY OF ARCADIA B ELD UNTIL ALL OBSERVED DEFICIENCIES ARE CORRECTED. , SIGNATURE OF CTURAL OBSERVER DATE STAMP OF STRUCTURAL OBSERVER) INIFonn.08(Pert 1)(Rev.11112007) www.ledbs.org o:. 1 City of Arcadia,CA - Permit No.FIRE-18-2147 I Development Services Department ¶_ • - Permit Type:Fire 1. I 240 Wes[Huntington Drive,Post Office Box 60021 Work Classification:Fire Sprinkler \\\i Arcadia,CA 91066-6021 __ - (626)574-5416 Permit Status:Issued ARCADIA issue Date:12/10/2018) Expiration: Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1109 Encino AVE Arcadia,CA 5780014032 Contacts YAMADA,GARY A AND LILY B Owner Superior Fire Protection' Fire Contractor(C-16) 1109 ENCINO AVE 18120 ROWLAND ST,CITY OF INDUSTRY,CA 91748 (626)623-2659 (626).965-6900 664427 1. Description:FIRE SPRINKS FOR SF ADD/ALT 34 HEADS Valuation: $ 3,400.00 Tenant Total Sq Feet: 0.00 , Plan Check#18-2147 Plan# Fees Amount Payments Amount Paid I Fire Issuance $44.35 Total Fees $882.40 Fire Permit Fees $137.05 Cash/Receipt#REC-002913-2018 $700.00 • Solid Waste Management Fee 2 $1.00 Cash/Receipt#REC-003093-2018 $182.40 Sprinkler Heads $700.00 Amount Due: $0.00 Total: $882.40 CALLS FOR INSPECTIONS Request for inspection by telephone at 626-574-5450. Leave a message requesting the address,timeframe and what inspection 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 Gythis permit is suspended or abandoned for 180 consecutive Clays or if no progressive work has been verified by a City of Arcadia building inspector for a period of 180 consecutive days. • 64 — December 10,2018 Issued By': Date December 10,2018 Page 1 of 1 of AR „y ra„ ;, 1 PERMIT/PLAN REVIEW APPLICATION ,n IP \4}j. 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 ICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION 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 l` I to L' rise No.C')�Q.11.L 'Exp. Date`L'20'1 at 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. NW t 1 OWNER-BUILDER DELLA' ON 1• �ave and will maintain workers'compensation insurance,as required by Section ❑ I hereby affirm under penalty of perju that I am e • pt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit License Law for the following reason(Sec . t 1.5,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 A 5C demolish,or repair any structure,prior to its issuance,also required the applicant c C e;1- ��Policy Number l ) 1t)C. for such permit to file a signed statement that he or she is licensed pursuant to thec7 (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 12'Ick •�8 sale(Section 7044,Business and Professions Code:The Contractors License nate 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'Compensano rage is unlawful, sale.If,however,the building or improvement is sold within one(I)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($100,000),in addition to the cost of compensation, did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and attorney's fees. ❑I, as owner of the property, am exclusively contracting with licensed • contractors to construct the project (Section 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097, Civil Code). ❑ I am exempt under Section 7044,Business and Professions Code,for this reason: Lender's Name Date Signature Lender's Address IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING: 1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel. 2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings and structures. 3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos. Please contact AQMD at(909) 396-2000 for further nformation. arae 'F'S- �$caJv to RPtz�GCMU Title c--r—k Vit.kyj.-Q.? PRINT NAME 0 1/JI 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. �7 ' nature �`� Date C..' (D ti4 Rv'"9'r .4 .Siae •1�,��\v;,. ea. �+ lv.ry.nW Aory!l.1Kl Y% MEMORANDUM Fire Department DATE: September 18, 2019 TO: BUILDING DEPARTMENT INSPECTOR Jeff Wang FROM: FIRE DEPARTMENT SUBJECT: FIELD INSPECTION ADDRESS: 1109 Encino Avenue THE FOLLOWING ITEMS WERE CHECKED FOR CONFORMANCE WITH APPLICABLE FIRE DEPARTMENT REQUIREMENTS: TYPE OF INSPECTION DATE / INITIAL FINAL INSPECTION FIRE SPRINKLERS 9-17-2019 Jill Perumean FIRE ALARMS TANKS HOOD & DUCT KNOX BOX OCCUPANCY 9-17-2019 Jill Perumean COMMENTS: Emailed Bldg. Dept. 9-18-2019 Rita „ took - WATER DIVISION ATTENTION: AF-r DATE: 7—g---17 I FROM: BUILDING DIVISION INSPECTOR: isffir ADDRESS: / /0 1 .ENOtIIb ?4V&'v PERMITNO.: MI/1-�Fu �11I PLAN NO.: 32,>72 CONTRACTOR:xj-j2I STo7P fl. IA,I !MAS PHONE NO.: 818--?t 3- 70.E.3 OWNER: . sae( 4. U I-`( 'fM ANDA PHONE NO.: 62.1)423 - 2 70.E-.3 PLEASE PLEASE INSPECT THE FOLLOWING ITEMS FOR CONFORMANCE WITH APPLICABLE DEPARTMENT OF PUBLIC WORKS REQUIREMENTS. Type of Inspection Date&Initial Date& Initial Final Approval i Meter Location X51 mA 3j1. i _ 19 6)13k il�(7 31er” � 9 5 Blackflow Devices r14-6 %--4vt- r til ti60 3-•LS- \D Irrigation System 673(4711-K1 1 '1-K1 Fire Sprinkler System Fla) 5'2 ,19 Meter Clear A.P.P. `c h 9• 2c t,5 I--k/ifs_ • Swimming Pool COMMENTS: F(tn-6 DIVAIb1 1' V' DG- M165---tar5 - 5v.'11, - ,..4 it CaA°w/1.cpt` tel Qttvic .Stc,,d6DoeF Eoa- O 17b4-10-( , t.IIrff rF AR STRUCTURAL OBSERVATION REPORT FORM STRUCTURAL OBSERVATION means the visual observation of the structural system,for general conformance to the approved plans and specifications,at significant construction stages and at completion of the structural system. Structural observation does not include or waive the responsibility for the inspections required by Section 108, 1701 or other sections of the code. - Report No.01 This report includes all construction work through 23rd day of October ,20 18 Page No. 1 of 1 Project Address: •• Structural Observer of Record(SOR): Phone No.of SOR: 1109 Encino Avenue,Arcadia, CA 91006 Thang Le, SE (626) 731-1539, Building Permit No.: Structural Observation performed by: Professional LiciReg.No.of Observer. Phone No.of Observer. Thang Le,SE S 4978 (626)731-1539 OBSERVED STRUCTURAL ELEMENTS AND THEIR CONNECTIONS I ELEMENTS/CONNECTIO FOUNDATION WALL FRAMES ROOF FLOOR OBSERVATION LOCATION ®Footing,Stem Walls, 0 Concrete 0 Steel Moment Frame ❑Concrete Footing reinforcement and hardware ❑Mat Foundation 0 Masonry ❑Steel Braced Frame 0 Steel Deck ❑Caisson,Piles,Grade 0 Wood 0 Concrete Moment 0 Wood Beams Frame 0 Retaining Foundation ❑Others: 0 Masonry Wall Frame 0 Others: Hillside Special Anchors ❑Others: 0 Others: ;NOTED DEFICIENCIES with the proposed corresponding corrective actions with respect to general conformance with the approved plans or in the load path: (A final report by the structural observer which states that all observed deficiencies have beenresolved is required before acceptance of the work by the building officials.) None. Okay to pour. I DECLARE THAT THE FOLLOWING STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE: 1. I AM THE ENGINEER OR ARCHITECT RETAINED BY THE OWNER TO BE IN RESPONSIBLECESS/0/04,CHARGE FOR THE STRUCTURAL OBSERVATION INACCORDANCEWITH THE REQUIREMENTS OF THE CITY OF ARCADIA. "I�2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UNDER m MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT EACH 03 f,` /1975 SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GENERAL f9 —M^� CONFORMANCE•WITH APPROVED PLANS AND SPECIFICATIONS; ` 'OWE`— 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED * S C..‘`..A� �� ABOVE; 7sT (tt� '`N QQ` 4. I RECOMMEND THAT ACCEPTANC T STRUCTURAL SYSTEMS BY THE CITY OF '9)e OF CA ��F ARCADIA BE WITHHELD UNTI L OBS VED DEFICIENCIES ARE CORRECTED. t° 14ag SIGNATURE OF STRUCTURAL SERVER 1`.DATE STAMP OF STRUCTURAL OBSERVER) INffoim.08(Pad I)(Rev.7112007) vrviw.latlbs.org • dif\,,,,_ / FITS INSPECTION SERVICES / 1/4'-1 /I OFFICE/CELL: (323) 630-9436 8990 KRISTIN DRIVE. •._______ 77 E-mail: daniel.sigala@sbcglobal.net DOWNEY, CA 90240 REGISTERED SPECIAUDEPUTY INSPECTOR- CERTIFICATE OF COMPLIANCE BUILDING DEPARTMENT kraA- Proj.Date /1//fig- Project D//giyProject Name Permit# /filo-2 7:-__/g-/41/5"-- Project /S'-/'/fCProject Address /1 Q 9 ��v 40 04-re-, 0,-TiL a� c.-0(1.Owner Name yeL.n-r,Pe Phone # Address General Contractor 6,4 5 J J %'44 'y Phone # • Address Fax# Site Contact clove Cell # Sub-Contractor - Phone # Address Fax# Engineering Firm Phone # Address Fax# TYPE OF INSPECTION Reinforced Concrete ❑ Shotcrete ❑ Gunite ❑ Rebar 1:j ")/16-ding - - ID Structural Masonry ❑ Prestress ❑ Anchors bolts El Dowels Fireproofing ❑ Post-Tension ❑ Framing ❑ Nailing Insp. ❑ Grading ❑ Others49,Iw,' Quality Control ❑ / Cylinders Samples Core Panels Mortar Grout Masonry prism To the Building Official Building Inspector I hereby certify that the following portions of the work at the above address which required Special/Deputy Inspection and for which I was employed to inspect, were inspected by me and comply with the applicable provisions of the Building Codes an. approved drawings. / , c ,, ,S- .i ' ,/P� /phi , peSQ, ` /e...2--.. `',P>1t� / —.,yorSGriW 1_---- e�� yf7 7?/L 2- 55"7'/`/ t------Y //d1, Inspector (Print): ` /.. i,G� License #: //// 7/.2 Type: Inspection Sign: ,.."..0:: � � Date: HOURS: on, Tues, Wed, Thur, j)( Fri, Sat, Sun, Verified By: (Print & Sign)