Loading...
HomeMy WebLinkAboutRALT-19-0148 "' City of Arcadia, CA Permit Aid. RALT-19-0148 Development Services Department J •` i'~;i \PerrnitType:Residential Addition/Alteration • 240 West Huntington Drive,Post Office Box 60021 tta =f' J k q i, i 1Work Classification Res-Addition/Alteration .."4„:1c. Arcadia,CA 91066-6021 y,; ; (626)574-5416 iw ,;.;;� Permit Status:Issued A° RCADIA Issue,Date:12/23/2019 f Expiration: Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip I Parcel Number 1759 Oakwood AVE Arcadia, CA 5765022022 Contacts BISHARA,NADER P AND Owner MARVIN FONG&ASSOCIATES* Applicant MAHROUS,VIOLA 1759 OAKWOOD DR (626)241-7321 MFONG@MF-AI.COM Danny Napolitano Contractor 1416 E 14th ST, Upland,CA 91786 (909)982-6173 875965 Description:FIRST AND SECOND FLOOR ADDITION. ENLARGE Valuation: $ 341,800.68 Tenant GARAGE,NEW COVERED PATIO.REMODEL FIRST FLOOR. WITH EMP,REWIRE HOUSE,200 AMP SERVICE. HVAC PER Total Sq Feet: 1,809.00 Plan Check#19-148 Plan#196 APPROVED PLANS.HERS REQUIRED FOR FINAL.**ADD TPP** TOTAL 4 BED 4 BATH Fees Amount Payments Amount Paid Bathtubs/or Combo $39.63 Total Fees $12,107.31 Building Issuing Fee $47.01 Cash/Receipt#REC-00193-19 $2,927.83 Building Permit Fees $2,893.80 Cash/Receipt#REC-03594-20 $49.44 Building Plan Review Fee $1,880.97 Cash/Receipt#REC-03424-19 $9,130.04 Cal Green Plan Check $188.10 Clothes Washer $13.21 Amount Due: $0.00 Compressor 3-5 Ton(3 to 15 hp) $36.35 Dishwasher $13.21 q� Electrical Permit Issuance Fee $47.01 6-N (I•S' i, 1 ` A'L� 111 COIJPiE1ED Energy Plan Review Fee $578.76 Furnace or Burner<=100,000 BTU $19.86 CALLS FOR INSPECTIONS Garbage Disposal Fee $13.21 Request for inspection by telephone at 626-574-5450. Leave a message Gas System(Outlets) $77.75 requesting the address,timeframe and what inspection item is needed. Green Building Standard $14.00 Install,Relocate Appliance Vent/Hood $9.94 Kitchen Sink $13.21 This permit/plan review expires by time limitation and becomes null and Laundry Trays $13.21 void if the work authorized by the permit is not commenced within 180 days Lavatories $79.26 from the date of issuance or if the permit is not obtained within 180 days Mechanical Permit Issuance Fee $47.01 from the date of plan submittal.This permit expires and becomes null and New Residential Elect.(sq ft area) $348.24 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 Parks&Recreation Fee(5FR) $5,155.65 Arcadia building inspector for a period of 180 consecutive days. Total: $12,107.31 December 23, 2019 Issued By: Date January 15,2020 Page 1 of 1 of ARC ,.,_,/ " „9 PERMIT/PLAN REVIEW APPLICATION Development Services Department,240 West Huntington Drive,Post Office Box 60021 \Y% 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 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 coverageis 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 occupancyof 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. I / i Lme u/ i ..�i . /0 I Title i /PRINT✓AME - - certify thatI have read this application and state that the above information is co rect and that I am the owner or duly authorized agent of the ower. I agree to comply with all City ordinances and State Laws relating to buildin construction. I hereby authorize representatives of the City of Ar dia to enter upon the above-mentioned property for inspection purposes. Si nature �� ,�,/ deb Date /`/Sr -0 17 J City of Arcadia, CA $� Permit NO RAL-149-0148 J Development Services Department =, 1, Permit Type'Residential Addition/Alteration• ., 240 West Huntington Drive,Post Office Box 60021 ;, , , i�- - , -"6 Arcadia,CA 91066-6021 P t w� zWorkClassification:Res Addition/Alteration �R (626)574-5416 ,..,,,,!,;,i: ,N % .� Permit Status'Issued-` ARCA r.IA Issue'Date 12/23/2019 1 Expiration• Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1759 Oakwood AVE Arcadia,CA 5765022022 -' _,., Contacts BISHARA,NADER P AND Owner MARVIN FONG&ASSOCIATES* Applicant MAHROUS,VIOLA 1759 OAKWOOD DR (626)241-7321 MFONG@MF-AI.COM Danny Napolitano Contractor 1416 E 14th ST,Upland,CA 91786 (909)982-6173 875965 Description:FIRST AND SECOND FLOOR ADDITION.ENLARGE t Valuation: $ 341,800.68 Tenant GARAGE,NEW COVERED PATIO.REMODEL FIRST FLOOR. WITH EMP,REWIRE HOUSE,200 AMP SERVICE. HVAC PERes Total Sq Feet: 1,809.00 Plan Check#19-148 Plan#196 APPROVED PLANS.HERS REQUIRED FOR FINAL. TOTAL 4 BED 4 BATH Fees Amount Payments Amount Paid Bathtubs/-or Combo $39.63 Total Fees $12,057.87 Building Issuing Fee $47.01 Cash/Receipt#REC-00193-19 $2,927.83 Building Permit.Fees $2,893.80 Cash/Receipt#REC-03424-19 $9,130.04 Building Plan Review Fee $1,880.97 Cal Green Plan Check $188.10 Amount Due: $0.00 Clothes Washer $13.21 Compressor 3-5 Ton(3 to 15 hp) $36.35 Dishwasher $13.21 Electrical Permit Issuance Fee $47.01 Energy Plan Review Fee $578.76 Furnace or Burner<=100,000 BTU $19.86 CALLS FOR INSPECTIONS Garbage Disposal Fee $13.21 Request for inspection by telephone at 626-574-5450. Leave a message Gas System(Outlets) $77,75 requesting the address,timeframe and what inspection item is needed. Green Building Standard $14.00 Install,Relocate Appliance Vent/Hood $9.94 Kitchen Sink $13.21 This permit/plan review expires by time limitation and becomes null and Laundry Trays $13.21 void if the work authorized by the permit is not commenced within 180 days Lavatories $79.26 from the date of issuance or if the permit is not obtained within 180 days Mechanical Permit Issuance Fee $47.01 from the date of plan submittal.This permit expires and becomes null and New Residential Elect.(sq ft area) $348.24 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 Parks&Recreation Fee(SFR) $5,155.65 Arcadia building inspector for a period of 180 consecutive days. Total: $12,057.87 09 December 23, 2019 Issued By: Date December 23,2019 Page 1 of 1 ,4.oFwAonite4it, PERMIT/PLAN REVIEW APPLICATION 4 Development Services Department,240 West Huntington Drive,Post Office Box 60021 mYaitY.fIV' 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 efff t. ❑ I have and will maintain a certificate of consent to self-insure for workers' License Classli Signature of Contr:ctor L'cense No. S'7�5-6K03 Exp. Date 30 Z i� cy'���— yI compensation, as provided for by Section 3700 of the Labor Code, for the 1 performance of the work for which this permit is issued. Signature of Contrac 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 1I 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 sub'ect to the workers'compensation provisions of Section 3700 o 7e La., od- I shall ❑I, as owner of the roe forthwith comply with those provisions. / property,rty, 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 Date 2=`�3 L Signator ,— 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 1'HE 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. 1 ,� r ,y /Name OA pi/i/ /V (9( 17-�•�" ` ( Title (2-eLC/ d7(�/v/ l 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 ' r rdinances and S .to Laws Hating to building construction. I hereby authorize representatives of the City of Arcadia to enter upon th• . •ove ii entioned pro y s'for in •ction purposes. \Signature 1 Date / Z—7- 3 / y 7 s-9 D4k1,1Oob ..ANE NOTES Building Inspections Date Insp. Plumbing Inspections Date. Insp. I 1 - b I TO 100. Setbacks 210. Under fir/bldg.drain ?S.Zc. Zo ----;- - 101. Rough grade 211. Copper underslab 102. Figs.&forms 3,u •=q---s 212. Rough plumbing •Z/ 2.111.24, &J I LD f',IC) ,..0tr,....) 492.0 v�� f•L� 103. Pre-slab 3 Z 213. Rough gas 104. Floor joists 3•24,..7,,, `13.../-214. Shower pan Z qr.e-ZO ,`--- -=i-v-(a5 -k,p p/ €t C"?c--e ' 105. Steel 215. Water heater GI dVe_fic(,F . .pfl->yo_ y3-- -- 106. _106. Grout lift 216. Roof drains 107. Shear nailing Frio 5-4.1.. .c--...._ 217. Building sewer $•31.Zo 'G•-- -3'26-44:, U F C"] *CI -- 108. Diaph nailing D.2(.L.'' 218. Water service 1•3)•19 -' i/•2.:e7 e_ s,'/ 1 - Ny d✓h2Sr - 109. Roof nailing S•(q•2.0 G••--- 219. Final gas 12.�6-Zo gr--- C_ 'Z3 Zo ?tet oa- S/1t t7N!'• '_ 110. Framing �•Z(.Zo 220. Fixtures , 111. Occ./Area Sept.Wall 221. Final plumbing T s•Z( .4 - 112. Sound walls 222. Sewer cap/demo. 113. T-bar'rid 0/6 grathe‘r-E '• '.3)• . j . ce, 114. Insulation-Flr. orPool Inspections Date Insp. 115. Insulation-Wall , . 240. Excavation/steel 116. Insulation-Ceil. / 241. Rough plumbing 117. Drywall nailing 5'Z)•77�`� 242. Light shell/bonding 118. Interior lath 9.t.Zo "----- 243. Underground conduit 119. Exterior lath g•(0.Za 244. P-trap 120. Finish grade 245. Gas line&test 121. Final building el'S-Z( a--- 246. Fence,gates&signs 122. Final demo/lot clear 247. Pool heater 248. Final electric Electrical Inspections Date Insp. 249. Final plumbing 150. Power pole I•go'Zo '.:1N------259. Pool cover 151. Sales lot lighting 251. Pool final 152. Underground conduit 153. Underslab conduit 3•ZG•Zo Reroof Inspections Date Insp. 154. UFER ground 2•2)7.10 270. Pre-reroof insp. 155. Water ground 271. Roof framing 156. Rough electrical ?./r.Ze 4 272. Sheathing nailing 157. Fixtures 273. Final reroof 158. G.FC.I. 159. E..t.bondin. Sign Inspections I Date I Insp. 160. Service panel I 2.11310 - 280. Setback/overhang 161. Final electric T•5-'7,( 'tom- 281. Footing 282. Conduit/wirin• Mechanical Inspections Date Insp. 283. Disconnect _ 180. Venting/flue 284. Final sign 181. Furnace/A.C. 182. Rouch HVAC "•Z/•Zs '1----- i i• ' •v'1 s 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 1).if.Zo 294. Hood dry chem. 188. Compressor setback 295. Final 189. Commercial hood 190. Duct shaft Sewers&Offsite Insp. I Date I Insp. 191. Final mechanical IFS-,2( 300. Lateral(main to P/L) 301. Saddle/Y Block Wall Inspections . Date Insp. 302. Gess soot filled 200. Footings 303. Sidewalk 201. Steel/rebar 304. Driveway 202. Grout lift 305. Curb replacement 203. Final wall 306. Trash bin MST CVa'xPALL ' c ��'.tor l' '� Nf �♦15' Fb.3.5,Fb-5i iir (WORMS II' .10 ill" `LAMN R, Fb..75' I I. I pE i I 6 i ! I ! ! ! EXIST 5'-b14 STEPPED j I GM1 WALL TO REMAIN LAWN ! �' � - ! ii .., , ilf i -15' Fb•O' IAil . VevrvaLe I0. i I t1,111. i 1 tirArco r+rcoiiiii, (E) �`0•iJ••*•:4••i flo ,RCA 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. 04 This report includes all construction work through 16th day of May , 20 20 Page No. 1 of Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1759 Oakwood Ave, 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, ❑Concrete ❑Steel Moment Frame ❑Concrete ❑ Mat Foundation ❑Masonry ❑Steel Braced Frame ❑Steel Deck ❑Caisson, Piles, Grade V Wood ❑Concrete Moment Vi Wood Roof,floor and wall Beams Frame framing;sheathing nailing and hardware. ❑ Retaining Foundation ❑Others: ❑Masonry Wall Frame ❑Others: Hillside Special Anchors ❑ Others: Slab-on-grade ❑ 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. 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 MO NA,FOR THE STRUCTURAL OBSERVATION IN ACCORDANCE WITH THE REQUIREMENTS "�( OF THE CITY OF ARCADIA. QQ.04 N F 2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UNDE- . 4l1 • `V 41 MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT EA► 4978 rn r SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GEN-- •L 013012 CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; • EXP• 0 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED •* Q� ABOVE; d', 5 C0 00 4. I RECOMMEND THAT ACCEPTANCE OF E ST CTURAL SYSTEMS BY THE CITY OF OF CP►�'�" ARCADIA BE WITHHELD UNTIL ALL SERVE EFICIE IES ARE CORRECTED. SIGNATURE OF STRUCTURAL OBSERVER DALE STAMP OF STRUCTURAL OBSERVER) IN/Form.0B(Part 1)(Rev.1/1/2007) ,vww.ladbs.org 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 22nd day of April , 20 20 Page No. 1 of 1 Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1759 Oakwood Ave,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 1 (626) 731-1539 OBSERVED STRUCTURAL ELEMENTS AND THEIR CONNECTIONS FOUNDATION WALL FRAMES ROOF FLOOR ELEMENTS/CONNECTION OBSERVATION LOCATION ❑ Footing, Stem Walls, ❑Concrete ❑Steel Moment Frame ❑Concrete ❑ Mat Foundation ❑Masonry ❑Steel Braced Frame 0 Steel Deck ElCaisson, Piles, Grade ❑Wood CIConcrete Moment J Wood Floor and wall framing; Beams Frame sheathing nailing and hardware. ❑ Retaining Foundation ❑Others: ❑Masonry Wall Frame ❑Others: Hillside Special Anchors ❑ Others: Slab-on-grade ❑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. 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 �Es.�►' • CHARGE FOR THE STRUCTURAL OBSERVATION IN ACCORDANCE WITH THE REQUIREMENTS Q�� OF THE CITY OF ARCADIA. pN4 N. 4 4 2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UNDE r MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT • 'H ( SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GEN-- •L S 4978 CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; tit -EXP 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED ti * e ABOVE; \ r'�rCO 4. I RECOMMEND T T ACC ANCE OF THE STRUCTURAL SYSTEMS BY THE CITY OF F OF CP ARCADIA BE THHELD TIL BSERVED DEFICIENCIES ARE CORRECTED. 20 o���y�7•0 SIGNATURE OF STRUCTU OBSERVER DTE STAMP OF STRUCTURAL OBSERVER) IN/Form.08(Part 1)(Rev.1/1/2007) www.ladbs.org r` JY Att. Alit;, 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 1st day of April , 20 20 Page No. 1 of 1 Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1759 Oakwood Ave,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 0 Footing,Stem Walls, ❑Concrete ❑Steel Moment Frame ❑Concrete ❑ Mat Foundation ❑Masonry ❑Steel Braced Frame ❑Steel Deck IDCaisson, Piles, Grade CIWood ❑Concrete Moment j Wood Floor framing and Beams Frame sheathing nailing. ❑ Retaining Foundation ❑Others: ❑Masonry Wall Frame ❑Others: Hillside Special Anchors ❑ Others: Slab-on-grade ❑ 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. 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 QikOFESS/0 CHARGE FOR THE STRUCTURAL OBSERVATION IN ACCORDANCE WITH THE REQUIREMENTS �NPN G `��2 OF THE CITY OF ARCADIA. • 2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UND MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT CH S 4978 SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GE RAL u EXP. 06/30/20 2 CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; *, 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED d" NUCTOP" ABOVE; 4. I RECOMMEND THAT ACCEPT O HE STRUCTURAL SYSTEMS BY THE CITY OF FBF Ci0O‘ ARCADIA BE WITHHELD U ALL SERVED DEFICIENCIES ARE CORRECTED. v O l/10 ZO SIGNATURE OF STRUCTU ERVER/ DATE • STAMP OF STRUCTURAL OBSERVER) IN/Form.08(Part 1)(Rev.1/1/2007) www.ladbs.org , •I r . I — ,' i e � 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 25th day of March , 20 20 Page No. 1 of 1 Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1759 Oakwood Ave, 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, ❑Concrete ❑Steel Moment Frame ❑Concrete Footing reinforcement, anchor bolts and ❑ Mat Foundation ❑Masonry ❑Steel Braced Frame ❑Steel Deck hardware. 0 Caisson, Piles, Grade ❑Wood ❑Concrete Moment ❑ Wood Beams Frame ❑ Retaining Foundation ❑Others: ❑Masonry Wall Frame ❑Others: Hillside Special Anchors ❑ Others: Slab-on-grade ❑ 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 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 RESPONSIBLE �ES�S'/0 CHARGE FOR THE STRUCTURAL OBSERVATION IN ACCORDANCE WITH THE REQUIREMENTS / H OF THE CITY OF ARCADIA. �l�Q` ' I- G (k.` c2 2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UNDER c/) Z MY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT EACH 0 '978 m SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GENERA u.1 cc. 4 P. 06/30/20 CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; * 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED (Pis s�UC�RP., �Q•• ABOVE; -1>),,"OF CA�1Fo 4. I RECOMMEND THAT ACCEPTAN F HE STRUCTURAL SYSTEMS BY THE CITY OF ARCADIA BE WITHHELD UN ALL 0 SERVED DEFICIENCIES ARE CORRECTED. 0)41 2®20 SIGNATURE OF STRUCTURA ERVER/ DATE STAMP OF STRUCTURAL OBSERVER) IN/Form.08(Part 1)(Rev.1/1/2007) www.ladbs.org :Lur as 1 „F 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 27th day of__ February , 20 20 Page No. 1 of 1 Project Address: Structural Observer of Record(SOR): Phone No.of SOR: 1759 Oakwood Ave,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, El Concrete ❑Steel Moment Frame ❑Concrete Footing reinforcement and anchor bolts. ❑ Mat Foundation ❑Masonry ❑Steel Braced Frame ❑Steel Deck ❑Caisson, Piles, Grade 0 Wood ❑Concrete Moment ❑ Wood Beams Frame ❑ Retaining Foundation El Others: ❑Masonry Wall Frame ❑Others: Hillside Special Anchors ❑ Others: Slab-on-grade ❑ 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 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 RESPONSIBLE O Q�OFES91'O42 CHARGE FOR THE STRUCTURAL OBSERVATION IN ACCORDANCE WITH THE REQUIREMENTS OF THE CITY OF ARCADIA.2. I,OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS UNDERMY RESPONSIBLE CHARGE, HAS PERFORMED THE REQUIRED SITE VISITS AT EACH wS 497, m SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GENERAL ' EXF' •i/ a 0 rn CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS; 7� 3. ALL NOTED DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED �> srR - RPS ��P ABOVE; F•F CALIFOck 4. I RECOMMEND T ACCEPTANCE OF THE STRUCTURAL SYSTEMS BY THE CITY OF , ARCADIA IT ELD UNTIL ALL OBSERVED DEFICIENCIES ARE CORRECTED.. a2/ SIGNATURE OF AL OBSERVER DATE STAMP OF STRUCTURAL OBSERVER) IN/Form.08(Part 1)(Rev.1/1/2007) www.ladbs.org THANG LE&ASSOCIATES STRUCTURAL ENGINEERS,INC. July 16,2020 Kenneth Fields,CBO,CASp Building Official Development Services Department 240 W.Huntington Drive P.O.Box 60021 Arcadia,CA 91066-6021 (626)574-5416 kfields@ArcadiaCA.gov Regarding: Notch in Wood Joist/Beam Bishara Residence 1759 Oakwood Ave Arcadia,CA 91006 Dear Mr.Fields: I hereby certify that I am responsible for the structural design of the construction described in the approved structural drawings dated July 16, 2019 of the above mentioned project. Due to field condition, the floor joists and beams were notched at several locations to receive plumbing pipe from above. We found that this structurally acceptable. Should you have any questions or require additional information,do not hesitate to contact us. Sincerely, - cfESSIQ p,\1G H. 4978 t D(PS06/30/22 114451kge' Thang Le,Ph.D., S.E. Principal 319 E. Foothill Blvd., Suite C,Arcadia,CA 91006 Phone: (626)731-1539 Email:thang@thanglese.com • - h�� -- - - - INSULATION CERTIFICATE IC-1 Site Address Permit Number 59 GZ -z.t°c, l' gG'c%1/ Number and Street City County Subdivision / Lot Numb r Description of Installation 1. ROOFH"F11 J i c Material ' S Brand Name < k AJ SVvl afv V//ie. Thickness(inches) 372— Thermal Resistance(R-Value) e 6,,1 1208 S 2. CEILING Batt or Blanket Type xrN+S ---- Brand Name t t9h,l S 1c?/V(i/ Thickness(inches) )'a,'t Thermal Resistance(R-Value) f.-3g Loose Fill Type ,v jF- Brand A o- Contractor's min installed weight/ft2 lb Minimum thickness /inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 3. EXTERIOR WALL Frame Type lit}'(,c2Z A. Cavity Insulatio — �, ` Materialr)(76-4S -� :9)Brand Name <I 11 S MaNV/ /e. Thickness(inches) a% Thermal Resistance(R-Value) )Z I5- / �_ • B B. Exterior` Foam Sheathing Material ""1//4• Brand Name /4//�¢ Thickness(inches) if Thermal Resistance(R-Value) 4. RAISED F" R / Material (-.4+'}- Brand Name 1.1/6 /94/o/e Thickness(inches) Cpl t Thermal Resistance(R-Value) 0-1�( 5. SLAB FLOOR/PERIMETER Material /v/ Brand Name �///( Thickness(inches) Thermal Resistance(R-Value) Perimeter Insulation Depth(inches) - • 6. FOUNDATION WALL ( r�l� Material n� f9' Brand Name �/ Thickness(inches) Thermal Resistance(R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Standards for residential buildings(Title 24,Part 6,California Code of Regulations)as indicated on the Certificate of Compli.i e,where a i plicable. /194(..- � �gItJ 7$ 1 '77t'31 Item#s ignature,Date l@S Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item#s Signature,Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item#s Signature,Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner r Compliance Forms August 2001 A-36 City of Arcadia SPECIAL INSPECTORS REPORT ADDRESS: 1759 Oakwood Ave. PROJECT NAME: Bishara Residence BUILDING PERMIT NO: RALT- 19-0148 This certifies that I performed special inspection on the following portion of the work at the above address: Located at foundation level for residence addition. Epoxy anchoring was was completed as per approved plans and MFG specs. Installed with Simpson Set Epoxy Adhesive. #4 dowels at(N)to (E)footing connections, under pin dowels at footing pads. 5/8"dia. all thread rods,A.B. holdowns(HDU5) 1"dia. all thread rods, Holdowns(HDU11). Inspection Passed. Beed on mama obsentatall and Britt repast,of this�'ig I s myjudgment hitt*Maks p ts]lolre bestki in centred freapprapad pans,speClidens,and Ile appEcehenlarrr;vh pfoisbrsdthe Gwen*Bti igCody 2/25/2020 .eclat Inspector's Signature Date Ismael Cordero. 310-930-5515 ICC/LA City 10106141P014491 Please Print Name Deputy Inspector Number cc: Client/Owner Architect/Engineer Mcc INTERNATIONAL nell CODE COUNCIL • City of Arcadia, CA Permit rvo. Meth=20-1058 � Development Services Department ,$i "� Permit Type Mechanicah 240 West Huntington Drive,Post Office Box 60021 ' Fr Arcadia,CA 91066-6021 Work Classification'[HVAC New System,Residential " 1 1 .',1‘; (626)574-5416 „ aSt.m . - �; - ,, ,,, . _� , , �", Permit atus; sued 'A. C DIA Issue'Date:07/14/20201 Expiration: 07/14/2021 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1759 OAKWOOD AVE Arcadia, CA 91006-1722 5765022022 .:'.,.- .:,, ..' ,, •- .. <.' .,,,. „Nk v Contacts BISHARA,NADER P AND Owner Danny Napolitano Contractor MAHROUS,VIOLA 1416 E 14th ST, Upland,CA 91786 1759 OAKWOOD AVE,Arcadia,CA 91006-1722 (909)982-6173 875965 NADERBISH@YAHOO.COM Description:INSTAL NEW MINI SPLIT IN FAMILY ROOM PER Valuation: $ 0.00 Tenant ____. APPROVED PLANS. (EA) Total Sq Feet: 0.00 Plan Check# Plan# ... .<._ . ..� .� � s Fees Amount Payments Amount Paid Furnace or Burner<=100,000 BTU $19.86 Total Fees $67.87 Mechanical Permit Issuance Fee $47.01 Cash/Receipt#REC-04953-20 $67.87 Solid Waste Management Fee 2 $1.00 Amount Due: $0.00 Total: $67.87 ',1,- COMPLETED _. . z.._____ .. 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. • July 14, 2020 Issued By: Date July 14,2020 Page 1 of 1 v~4°tF 1 4,,,1 - ,. kr PERMIT/PLAN REVIEW APPLICATION • 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: )1 Chapter 9(commencing with Section 7000,of Division 3 of the Business and Professions Code,and my license is in full force and effect. El 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 abor C C.i e,I shall • IDI, 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 7-��"W 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.loore Name 0 l !o ©( (-r � Title S(Old-�I ✓✓ 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 ord'.: • and State Laws relating to building construction. I hereby authorize representatives of the City of Arcadia to enter upon the above-:. •ntio 1 •i prop r i ction purposes. Signature Date ‘7'-14 m1 City of Arcadia, CA -JI Permit NO. FIRE-20-0238 " Development Services Department Permit'Type.Fire ''Ii240 West Huntington Drive,Post Office Box 60021 °Y= Arcadia,cA 91055-5oz1 Work •Classification Fire Sprinkler , (626)574-5416 a, N` PermitStatus'Approved AIDCAD1A s Zo 'Issue Date: •Expiration. 08/09/2020 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1759 OAKWOOD AVE Arcadia,CA 91006-1722 5765022022 .:WU, " .,.-le,. _ Contacts •- - BISHARA,NADER P AND Owner CRAIG FIRE PREVENTION* Contractor MAHROUS,VIOLA 123 E CENTRAL AVENUE AVE,MONROVIA,CA 91016 1759 OAKWOOD AVE,Arcadia,CA 91006-1722 (626)357-4045 1037827 NADERBISH@YAHOO.COM Description:FIRE SPRINKS FOR SF NEW 52 HEADS t Valuation: $ 7,800.00 Tenant li Total Sq Feet: 0.00 Plan Check#20-238 Plan# Fees Amount Payments Amount Paid Fire Issuance $47.01 Total Fees $951.86 Fire Permit Fees $203.85 Cash/Receipt#REC-04538-20 $251.86 Solid waste Management Fee 2 $1.00 Cash/Receipt#REC-03824-20 $700.00 Sprinkler Heads $700.00 Amount Due: $0.00 Total: $951.86 - GOMLETE D 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. Issued By: Date May 26,2020 Page 1 of 1 ir.14 oFFtRRAI 9.7, i PERMIT/PLAN REVIEW APPLICATION 5tha.. r-a ° w) Development Services Department,240 West Huntington Drive,Post Office Box 60021 °alt,°fIt° Arcadia, CA 91066-6021, (626) 574-5416,Fax(626) 447-9173 City of Arcadia IICENSED 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: hapter 9(commencing with Section 7000,of Division 3 of the Business and rofessions Code,an my license is in full orc and elleg�-- I have and will maintain a certificate of consent to self-insure for workers' cense Class Lice se !o. J v Exp. Date 0 i 2 compensation, as provided for by Section 3700 of the Labor Code, for the gnature of Contractor f, ��/ performance of the work for which this permit is issued. WNER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section 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 icense 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 ❑II 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 ❑ property, or my employees with wages as their sole forthwith comply with those provisions. I, as owner of thep y p compensation,will do the work,and the structure is not intended or offered for,_ - , " _ - y — -,,,3. .€ ,. sale(Section 7044,Business and Professions Code:The Contractors License ® S7`gniaattmre `' = 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 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 tfurther information. r /' Sc " n F ame u / dt J' 4 V! Title "'iI TNAME 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-mentioned property for inspection purposes. ©�—/�/� ignature " Date