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FTIQVD21V •panss!:snloJS,liwlad - - - 9TVS-VLS(9Z9) • !epuap!say looaaa uoUooyissolJ laoM {TURF- �} Tzo9 990T6 yJ'e!pe»y !,9 c y TZ009 xog aolyO lsod'anu0 uol2upunH lsaM 042 ;00y.:adAl*wad 1.1J �.n.. I ® luawlledeo sa]!n1aS wawdo!ana0 fl9T-6i-d0011 - •— to 'e!pep'y}O !D , .Q.0 .FAR I. 40 oyVORvL,• 4 PERMIT/PLAN REVIEW APPLICATION * 'II zCi*' 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_C 3 9 License No. 71/0 SU Exp. Date 9-So-I' C.. Signature of Contractor compensation, as provided for by Section 3700 of the Labor Code, for the ?`_ performance of the work for which this permit is issued. ir�- OWNER-BUILDER DECLARATION la r 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'c-ompens tion ins ce carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carver S/4'7Y /1 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 p Y G/� provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completedifthe 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 ofcertify 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. /jam" ❑ e work,and employees withtwages as their sole % / compensation,will do the the structure is not intended or offered for Date €-/q- /q sale(Section 7044,Business and Professions Code:The Contractors License 11 S'� 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: Failme'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: 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. arae /14,0V e eaS71fraTitle ©Ws-�� PRINT NAME I certify that I have read this application and state that the above information is co t 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 tea S - (Date S- ( 9-1 /