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TI-19-1836
,ir w .••'•,. City of Arcadia, CA Permit NO.TI-19-1836 Development Services Department Permit Type:Tenant Improvement 240 West Huntington Drive,Post Office Box 60021 r Arcadia,CA 91066-6021 Work Classification:Tenant Improvement (626)574-5416 Permit Status:Issued ARCADIA Issue Date:03/23/20201 Expiration: Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number L1020 S Baldwin AVE Arcadia,CA 5778006010 1 Contacts ANKAA LIVE PLAZA, LLC Owner JENNY XU Applicant (626)715 1485 615 LAS TUNAS DR 205,ARCADIA,CA 91006 (626)388-4919 4 KING SAN WONG* Contractor 439 S ALMANSOR,ALHAMBRA,CA 91801 (626)780-8366 .,, 782163 o Description:T.I.ANKAA LIVE PLAZA Valuation: $ 300,000.00 Tenant ANKAA LIVE PLAZA Total Sq Feet: 0.00 Plan Check#19-1836 Plan#242 Fees Amount Payments, Amount Paid Accessibility Plan Check $253.89 Total Fees $6,130.21 Accessiblity Building Permit $260.40 Cash/Receipt#REC-04134-20 $3,213.66 Building Issuing Fee $47.01 Cash/Receipt#REC-02452-19 $2,916.55 Building Permit Fees 52,604.00 Building Plan Review Fee $1,692.60 Amount Due: $0.00 Cal Green Plan Check $169.26 -' Commercial T.I.Fire Plan Chk. $280.00 Energy Plan Review Fee $520.80 Fire Final Occupancy Fee $200.00 Green Building Standard $12.00 Solid Waste Management Fee $6.25 CALLS FOR INSPECTIONS Strong Motion Inst.Program Com $84.00 Request for inspection by telephone at 626-574-5450. Leave a message requesting the address,timeframe and what inspection item is needed. Tota l: $6,130.21 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 ki-ii compiEm: consecutive days or if no progressive work has been verified by a City of ' Arcadia buildinginspector foraperiod of 180 consecutive ecus a days. -Z3-2l 1,(c, / March 23, 2020 Issued By: Date March 23,2020 Page 1 of 1 II A; w mFo �'. PERMIT/PLAN REVIEW APPLICATION 1 ,,, 4y' , Development Services Department,240 West Huntington Drive,Post Office Box 60021 `� �` Arcadia,CA 91066-6021,(626)574-5416,Fax(626)447-9173 nnl,y oL� City of • Arcadia0 o LICENSED CONTRACTOR'S DELLA ON WORKERS'COMP SATION DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under pen ty 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. License Class icense No./ 2 R7 0 I have and will maintain a certificate of consent to self-insure for workers' 6Z Exp. tdV compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Signature of Contractor DECLARATION I have and will maintain workers'compensation insurance,as required by Section I OWNER-BUILDER under penaltyof that I am exempt from the Contractors 3700 of the Labor Code,for the performance of a work for which this permit ❑ hereby perjury P issued.My workers'compensation insurance 'er and policy numbers are: License Law for the following reason(Section 7031.5,Business and Professions 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 O pi , for such permit to file a signed statement that he or she is licensed pursuant to the (This section need not be completed if a permi 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 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 not employ any person in any manner so as to become subject to the workers' Section 7031.5 by any applicant for a permit subjects the applicant to a civil compensation Laws of California,and agree that if I should become subject to the penalty of not more than five hundred dollars($500)): workers'compensation provisions of S: ti. 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;--2 0-00 Signature,Fr ft,A 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 her information. ,�>,/�e (/J Title'' I'RP1T NAMELame_? ertify 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 co , ly with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of rcadia to e, •r upon the/abovementioned property for inspection purposes. gnature 1 Date , 2.77 `.7rO?ia NOTES Building Inspections Date Insp. Plumbing Inspections Date Insp. 1pZv 3 / �/ r,('r,11/V( . 100. Setbacks 210. Under flr/bldg.drain / ✓f�'�-���1 101. Rough grade 211. Copper underslab 102. Figs.&forms 212. Rough plumbing 103. Pre-slab 213. Rough gas 104. Floor'oists 214. Shower.an .5-7-1q-2O `k---er-eccf lam, 105. Steel 215. Water heater /' �r A2r-�-�-. �yu D 106. Grout lift 216. Roof drains l,�•,��{{��.,���� '� N`1 ' v, 107. Shear nailing 217. Building sewer 4ek L i-os{. ,�.i ��L'g. V 108. Diaph nailing 218. Water service - -EMT sive) at- "Ni, 109. Roof nailing 219. Final gas _ 110. Framing 7-2(3-Zc »- 220. Fixtures e 6.../G-/G'Zo 5 cA. j3-6w4c .S:4„...,111. Occ./Area Sept.Wall G 221. Final plumbing + I(-?-f j �v1c. i 4 l 112. Sound walls 222. Sewer cap/demo. ,,,J ��,-J ,�y, 113. T-bar grid 7-2`�-Z M • ' ASa NrrRCe,'s,UrC -�'-Zo Aar 4'4 7-� �u�P' 1 CLX - OF f-I `C!t 114. Insulation-Fir. Pool Inspections Date Insp. �02.4j . /2) LTV t-t 115. Insulation-Wall 240. ExcavRough plumbing ',/l 1 l on/steel 116. Insulation-Ceil. 241. Rough plumbing V 117. Drywall nailing`-Z�b 242. Light she/bonding G-ZG-Zc- ul�t7F-26•Kcs.-460 & 1>uir-S 118. Interior lath 243. Underground conduit /p 119. Exterior lath 244. P-trap �� X- . Ml.iG 1AR S R- 02- ��oTS �� 120. Finish grade 45. Gas line&test (,3cs ZO S G4,i3 pc,c..tEZ,3 1 ‘.5 C2' 121. Final building 4-23-7.7 46. Fence.gates&signs 122. Final demo/lot clear ` 247. Pool heater /�GTTCiL 2'(£i`e«sS 1 z S 7a.CTS 248. Final electric .8j4„L .A,.41-s �! /Electrical Inspections Date Insp. 249. Final.lumbin. 712-c-- ) - i' e-,_:.-,77-1.,, ( 1, /A,vG.150. Power pole 250. Pool cover _ 151. Sales lot lighting 251. Pool final P 1., 775 14.7- /4-tA/f! i 2._o2, / 152. Under.round conduit ift .153. Underslab conduit Reroof Inspections Date I Insp. -,Y ZU /Ic-L frQ/3�cs/,.lC- 154. UFER ground 270. Pre-reroof insp. 6-1-20 :144 /c--Zcs 7- --,..IccK! TE$i 4=aK Z 155. Water ground71. Roof framing l4�li� 156. Rough electrical 7_ lb/f- ` 272. Sheathing nailing 157. Fixtures %-eliA 7-24,-z ,-,y/ 273. Finalreroof -7-Zo-ZV 2 G�Yc4S 3-� 159. . / / E'.t. 159. t.bonding Sign Inspections Date Insp. F'�`�A`s'- &Al fIQo0 0 vGrS 160. Service panel 280. Setback/overhang 747-7-0 VRJ(trA[,L AT SPaA.iS 161. Final electric 6-/I-ZI 76 281. Footing 282. Conduitwirin. erFFicg�S exir Go/�RoDbc Mechanical Inspections Date Insp. 283. Disconnect 8-a-2.0. ISA- A.C.C. OA! GE/U..1 6-- aF_ 180. Venting/flue 284. Final sign Kerr lE,, ,-,fir C,,PQ.bD6R.+ fied>"1rtjs,p£ 18 . A.C. 182. Rouch HRouch HVAC 7-/5-Zc> 4,A=4,A= u' • .n•on Insp. Date Insp. /4.404::.FFic6 S ` 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. Commercial hood 2--/-7-( /. 190. Duct shaft Sewers&Offsite Insp. I Date Insp. 191. Final mechanical `'/&'u .+./300. Lateral(main to P/L) 301. Saddle/Y Block Wall Inspections Date Insp. 302. Cess..ol filled 200. Footings 303. Sidewalk 201. Steel/rebar 304. Driveway 202. Grout lift 305. Curb replacement 203. Final wall 306. Trash bin _ _ /`\\. �\ /��� J \ \ ,' \� \ \ /.', �, �' \rte• / \ J`\� j\ /J ��\\ '\ r7 gyp:.- ./ 7\ %.� y\1 -..., ,..\ .)"\\'1 CD — \ i,' s L41 = B n d Z 0 a Cie ` i a ! ` r w c� t� N ' �\ r\ 7";;''; E. < td 8 /J./ \ 3 07 v I I� n ?. c S et y $ H ."-s.. lit o n g'Z c g• r- r !y, -a 0 Al. vii, i,..J/ 1\ f 1 ..© Z, i 4. 1 ‘-r-: o ►D HI e ` `moi 00 �_1 a P , ...,.._,.:_k: �] . t�f W a •. }, \ /l'7,.V.:‘ilam' i °0 ° va 0 n as O ^ / 1; n '0- E (\ \, , 1 c. 0. \ i Mo� i ,,,,\ / y ! ,-, , • J , V City of Arcadia, CA Permit NO. MEP-21-1136 Development Services Department Permit Type: MEP 240 West Huntington Drive,Post Office Box 60021 1 Arcadia,CA 91066-6021 Work Classification:MEP-Commercial (626)574-5416 Permit Status:Issued ARCADIA Issue Date:06/22/2021 Expiration: 06/22/2022 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1020 S Baldwin AVE Arcadia,CA 91007-7234 5778006010 Contacts JOHNSON PAN Agent for owner SOUTH LAKE 12 LLC AND CYTS USA LLC Owner 153 Hudson, Pasadena,CA 910014992 (626)715-1386 Description: MEP FOR TI.3 200A SUB PANELS Valuation: $ 0.00 Tenant Total Sq Feet: 0.00 Plan Check# Plan# , Fees Amount Payments Amount Paid Compressor 3-5 Ton(3 to 15 hp) $181.75 Total Fees $1,354.46 Dishwasher $13.21 Cash/Receipt#REC-07970-21 $1,354.46 Distribution Panel $49.44 Amount Due: $0.00 Electrical Permit Issuance Fee $47.01 Floor Drain Fee $105.68 Floor Sink $118.89 Gas System(Outlets) $32.83 Hood Serviced by Mechanical Exhaust $29.92 Interceptor $26.27 Kitchen Sink $171.73 Lavatories $66.05 CALLS FOR INSPECTIONS Light Fixtures $170.40 Request for inspection by telephone at 626-574-5450. Leave a message Mechanical Permit Issuance Fee $47.01 requesting the address,timeframe and what inspection item is needed. Outlets-Receptacles&Switches $64.40 Plumbing Permit Issuance Fee $47.01 Sewer Connection on Property $33.01 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) $49.70 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 $66.05 Arcadia building inspector for a period of 180 consecutive days. Total: $1,354.46 COMPLETED June 22, 2021 Issued By: Henry Kemick Date August 06,2021 Page 1 of 1 • PERMIT/PLAN REVIEW APPLICATION (.,� a Development Services Department, 240 West Huntington Drive,Post Office Box 60021 4.4.1.y of 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 performance of the work for which this permit is issued. Signature of Contractor ❑ I have and will maintain workers'compensation insurance,as required by Section OWNER-BUILDER DECLARATION 3700 of the Labor Code,for the performance of the work for which this permit • I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less) 7000)of Division 3 of the Business and Professions Code)or that he or she is 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 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. 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. 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 !"!,.! %<$2,_>, `"'4`�' WATER DIVISION A*1 TENTION: Epic DATE: S-19-x/ FROM: BUILDING DIVISION INSPECTOR: AsAl47 Al.-fuck ADDRESS: IOZo 5 . eALr>c�r�,.i PERMIT NO.: 19 !$3 PLAN NO.: 2 4z.. CONTRACTOR: K/r4o. Sisy i Lr0,0‘ PHONE NO.: 424 7 '7 g cs g 36 G OWNER: /INKAA 4,1 vc AA-Zit ILC PHONE NO.: PLEASE INSPECT THE FOLLOWING ITEMS FOR CONFORMANCE WITH APPLICABLE DEPARTMENT OF PUBLIC WORKS REQUIREMENTS. Type of Inspection Date& Date&Inittial Final Approval Meter Location Blackflow Devices - 5/a7/a Irrigation System 1 5/ -- /a1 Fire Sprinkler System Meter Clear A.P.P. - '�$ 5/D."7 b• Swimming Pool 5/ "7/?. X00~ Soo CAl1 COMMENTS: I re, . Li Dc., N4E5 PLo 14- w,�1-�S L F ons M S (*-D3'v-i meAe r - -- AQ P l,ham -lo I.71.6.,72- R- 0000__ --- --- . 4,401 . 0-1 fit WATER DIVISION A JTENDON: £E t— DATE: g_/9_7-4 FROM: BUILDING DIVISION INSPECTOR: tosAtity XsiiCk ADDRESS: iaz..o 5 • e Ac_,)c.si,.i • PERMIT NO.: 19 1E53 PLAN NO.: 2 yZ CONTRACTOR: Kyrie Si6.1 Lia/.4‘ PHONE NO.: 424/ 7aa -g 3‘ OWNER: 1NKa4_ Ft.e,-ZA- ac PHONE NO.: PLEASE INSPECT THE FOLLOWING ITEMS FOR CONFORMANCE WITH APPLICABLE DEPARTMENT OF PUBLIC WORKS REQUIREMENTS. Type of Inspection Date& Initial Date&Initial Final Approval Meter Location Blackflow Devices Irrigation System . 5� Fire Sprinkler System �i� S�a�/� I Meter CIear A.P.P. 5 �7�� t Swimming Pool 306 GNI' COMMENTS: ce • Li DC, AMCs L CLQ I-t- (ji— 13p4 tiSS : "V " G w ■ 1.7M5 (* c A1\p e� = --`b.._-_�leQ�n� ►o�-7°i6,2a. . R- 0000 _^.- i PLANNING SERVICES ATTENTION: 1/j1,J£5Sti DATE: 5-/9 -2-/ FROM: BUILDING SERVICES INSPECTOR: Weit44-7 PROPERTY ADDRESS: /0 2-ct. 8 4 c 171A7 d,./ PERMIT#: /9 - 1.536 PLAN#: 2 (12- CONTRACTOR: ZCONTRACTOR: /<' ,-i(- ,54,4/ h!a../G PHONE#: 6267715a---A5 GC OWNER: ANk &/--' JJvc 7 42 - c-c PHONE#: PLEASE INSPECT THE FOLLOWING ITEMS FOR COMFORMANCE WITH APPLICABLE PLANNING REQUIREMENTS. TYPE OF INSPECTION DATE& INITIAL DATE& INITIAL FINAL APPROVAL LANSCAPING/IRRIGATION ( CV( 12 I TRASH ENCLOSURES PARKING/DRIVEWAYS STORAGE AREAS MECHANICAL EQUIPMENT WALL HEIGHT BACKFLOW SCREENING li , r COMMENTS: I)- atom 1 rt -1141 City of Arcadia DEVELOPMENT SERVICES DEPARTMENT Inter-Departmental Inspection Request Date: - Y-21 Public Works Inspector To: From: KE' "-' Address: (rszc 5. frac-c wi^.i Permit No.: (ci - 1233G Contractor: (<i.(6- 5j�,,,, IA/0/.4G Phone No.: 6,z 77So 83 cc- Owner: GOwner: ANKA/A L1✓'g 74-42-A- cc c- Phone No.: Please inspect the following items to ensure that the Contractor/Developer is in compliance with all conditions of approval established for the project, and that the work performed meets the City's standard for Public Works construction: Type of Inspection Date&Initial Date&Initial Final,Appy v l Drainage Grading Erosion Control Offsite Improvements Street Improvement(s) (conduit, curb/curb & gutter,curb numbers, driveway approach, parkway planting, sidewalk, street light, traffic flow, etc.) _ Sewer(s) (lateral, grease/san interceptor, saddle, wye, etc.) COMMENTS: i('t'►—PCS .DG `-31 r 1 Ac" 'i)Cr)i)t „Al 5 , q-1 \-1/k`6 ' ....1,12/11 6 � FRR1t4 4 d1! r v 7 111 0. I...ro.....a is Avry.i , 90J 9 C°0\y o%a MEMORANDUM Fire Department DATE: June 14, 2021 TO: BUILDING DEPARTMENT INSPECTOR Henry Kemich FROM: FIRE DEPARTMENT SUBJECT: FIELD INSPECTION ADDRESS: 1020 S. Baldwin Avenue THE FOLLOWING ITEMS WERE CHECKED FOR CONFORMANCE WITH APPLICABLE FIRE DEPARTMENT REQUIREMENTS: TYPE OF INSPECTION DATE / INITIAL FINAL INSPECTION FIRE SPRINKLERS (PC# 20-713) 4-7-2021 Jill Perumean FIRE ALARMS (PC# 20-816) 3-23-2021 Alex Foskarino HOOD & DUCT (PC# 20-922) 3-23-2021 Jill Perumean KNOX BOX OCCUPANCY (PC# 19-1836) 6-8-2021 Jill Perumean COMMENTS: Emailed Bldg. Dept. 6-9-2021 Rita t COUNTY OF LOS ANGELES• DEPARTMENT OF PUBLIC HEALTH /OT ENVIRONMENTAL HEALTH + 1,A��..�s. SPECIALIZED SURVEILLANCE AND ENFORCEMENT BRANCH PLAN CHECK PROGRAM-BALDWIN PARK Cowin,Orlos ANGELIS cAl,F0100'' 5050 COMMERCE DR, BALDWIN PARK,CA 91706 Public Health PHONE: (626)430-5560 VVAWPUBLICHEALTH LACQUNTY GOWEH PLAN CHECK OFFICIAL INSPECTION REPORT DATE 06/14/2021 EHS ADRINE IBRANYAN PLAN CHECK NUMBER SR0197748 PROGRAM ELEMENT 1705- RESTAURANT(10,000 SF OR MORE) OWNER/REQUESTER JENNY XU, DESIGNER DBA ANKAA LIVE PLAZA ADDRESS 1020 S BALDWIN AVE, ARCADIA, CA 91006 FINAL REINSPECTION STATUS: APPROVED CORRECTIONS COMPLETED CORRECTION CATEGORY DATE IDENTIFIED DATE CORRECTED FLOOR BASE COVING 04/06/2021 04/28/2021 WALLS 04/06/2021 04/28/2021 JANITORIAL FACILITIES 04/06/2021 04/28/2021 TOILET FACILITIES 04/06/2021 04/28/2021 WATER SUPPLY 04/28/2021 05/12/2021 EQUIPMENT/STORAGE 04/06/2021 04/28/2021 EQUIPMENT/STORAGE 04/28/2021 05/12/2021 LIGHTING/ELECTRICAL 04/06/2021 04/28/2021 VERMIN EXCLUSION/ENCLOSURE 04/06/2021 04/28/2021 PLAN SUBMITTAL/REMODEL 04/06/2021 05/12/2021 ADDITIONAL REQUIREMENTS NONE Help us serve you better by completing a short survey.Visit our website at . 'iw publichealtn lacounty qov/eh. A\ I EHS Signature Page 1 of 3 PLAN CHECK OFFICIAL INSPECTION REPORT DATE 06/14/2021 EHS ADRINE IBRANYAN PLAN CHECK NUMBER SR0197748 PROGRAM ELEMENT 1705- RESTAURANT(10.000 SF OR MORE) OWNER/REQUESTER JENNY XU. DESIGNER DBA ANKAA LIVE PLAZA ADDRESS 1020 S BALDWIN AVE, ARCADIA, CA 91006 COMMENTS THIS RETAIL FOOD FACILITY IS APPROVED TO OPERATE. THE PROVISIONS OF THE CURRENT HEALTH OFFICER ORDER ARE IN EFFECT AND SHALL REMAIN IN EFFECT UNTIL EXTENDED. RESCINDED, SUPERSEDED, OR AMENDED, TO KEEP UP TO DATE WITH THE MOST RECENT HEALTH OFFICER ORDER REQUIREMENTS, PLEASE VISIT OUR WEBSITE AT HTTP://PUBLICHEALTH.LACOUNTY.GOV/MEDIAJCORONAVIRUSI BEGINNING MARCH 1, 2021 FOOD AND AGRICULTURE WORKERS WHO LIVE OR WORK IN LOS ANGELES COUNTY ARE ELIGIBLE FOR VACCINATION AGAINST COVID-19. THE VACCINE IS BEING PROVIDED AT NO COST REGARDLESS OF HEALTH INSURANCE OR IMMIGRATION STATUS. THE ATTACHED DOCUMENTS CONTAIN INFORMATION ON THE VACCINE,WORKER ELIGIBILITY, HOW TO GET VACCINATED,AND WHAT DOCUMENTATION YOU WILL NEED TO PROVIDE TO RECEIVE YOUR VACCINE. PLEASE PROVIDE THIS INFORMATION TO YOUR EMPLOYEES. Help us serve you better by completing a short survey.Visit our website at www oubl chealth lacounty gov/eh. A I EHS Signature Page 20f3 PLAN CHECK OFFICIAL INSPECTION REPORT DATE 06/14/2021 EHS ADRINE IBRANYAN PLAN CHECK NUMBER SR0197748 PROGRAM ELEMENT 1705-RESTAURANT(10,000 SF OR MORE) OWNER/REQUESTER JENNY XU, DESIGNER DBA ANKAA LIVE PLAZA ADDRESS 1020 S BALDWIN AVE,ARCADIA, CA 91006 DISCLOSURES It is a misdemeanor violation to begin operation without a valid Public Health Permit/License.The Public Health Permit/License will be issued by the Los Angeles County Department of Public Health Environmental Health Division(DPH-EH)Plan Check Program at the job site following final inspection and approval by all applicable agencies. Remodeled areas of an existing food facility/establishment must obtain a final inspection and approval from all applicable enforcement agencies prior to use. Any future alteration,construction,building,renovation,repair,change of equipment,change of the operation of a food facility/establishment or change of menu may require plans to be submitted to the DPH-EH Plan Check Program. Additional approvals may be required from other enforcement agencies. It is improper and illegal for any County officer,employee or inspector to solicit bribes,gifts or gratuities in connection with performing their official duties. Improper solicitations include requests for anything of value such as cash,discounts,free services,paid travel or entertainment,or tangible items such as food or beverages. Any attempt by a County employee to solicit bribes,gifts or gratuities for any reason should be reported immediately to either the County manager responsible for supervising the employee or the Fraud Hotline at(800)544-6861 or www.lacountyfraud.org. YOU MAY REMAIN ANONYMOUS Public Health Permit/License: A separate fee is required for the Public Health Permit/License.A billing statement will be sent to the permit/license holder annually by the DPH-EH. The fee is required to be paid to perform or carry on,conduct or engage in any mobile food facility listed in Los Angeles County Code,Title 8,Section 8.04.720. State and Local Licenses and Permits: Contact the State of California and your local city hall regarding additional license and permit requirements. Restrooms: Customer may use restroom facilities if they are located in a customer area.Customers may not enter the food preparation area,food storage area,or the utensils washing/storage areas in order to access the restrooms.All food,utensils and equipment must be protected from contamination. Routine Inspection:The DPH-EH conducts routine inspections of all food facilities in Los Angeles County. Following the issuance of your Public Health Permit by the Plan Check Program,an Environmental Health Specialist from your local district will conduct an inspection of your facility. If your Business is located in a city that has adopted the grading ordinance,the inspector will post a grade or score card at your facility. Grade/Score cards are not issued by the Plan Check Program. Help us serve you better by completing a short survey.Visit our website at www publichealth lacounty Qovieh. A. I. EHS Signature Page 3 of 3 oras COUNTY OF LOS ANGELES • DEPARTMENT OF PUBLIC HEALTH ENVIRONMENTAL HEALTH + SPECIALIZED SURVEILLANCE AND ENFORCEMENT BRANCH }} PLAN CHECK PROGRAM -BALDWIN PARK COUNTY or LOSANGILIS c+urow,-' 5050 COMMERCE DR, BALDWIN PARK,CA 91706 Public Health PHONE:(626)430-5560 V`VWV.PUBLICHEALTH.LA000NTY GOV/EH PLAN CHECK OFFICIAL INSPECTION REPORT DATE 06/14/2021 EHS ADRINE IBRANYAN PLAN CHECK NUMBER SR0198943 PROGRAM ELEMENT 1703-RESTAURANT(2,000-3,999 SF) OWNER I REQUESTER JENNY XU, DESIGNER DBA ANKAA LIVE PLAZA-BAR ADDRESS 1020 S BALDWIN AVE,ARCADIA, CA 91006 FINAL REINSPECTION STATUS: APPROVED CORRECTIONS COMPLETED CORRECTION CATEGORY DATE IDENTIFIED DATE CORRECTED EQUIPMENT/STORAGE 04/06/2021 04/28/2021 PLAN SUBMITTAUREMODEL 04/06/2021 04/28/2021 PLAN SUBMITTAL/REMODEL 04/28/2021 05/13/2021 ADDITIONAL REQUIREMENTS NONE COMMENTS THIS RETAIL FOOD FACILITY IS APPROVED TO OPERATE. THE PROVISIONS OF THE CURRENT HEALTH OFFICER ORDER ARE IN EFFECT AND SHALL REMAIN IN EFFECT UNTIL EXTENDED, RESCINDED, SUPERSEDED, OR AMENDED. TO KEEP UP TO DATE WITH THE MOST RECENT HEALTH OFFICER ORDER REQUIREMENTS, PLEASE VISIT OUR WEBSITE AT HTTP://PUBLICHEALTH.LACOUNTY.GOV/MEDIA/CORONAVIRUS/ BEGINNING MARCH 1, 2021 FOOD AND AGRICULTURE WORKERS WHO LIVE OR WORK IN LOS ANGELES COUNTY ARE ELIGIBLE FOR VACCINATION AGAINST COVID-19. THE VACCINE IS BEING PROVIDED AT NO COST REGARDLESS OF HEALTH INSURANCE OR IMMIGRATION STATUS. THE ATTACHED DOCUMENTS CONTAIN INFORMATION ON THE VACCINE,WORKER ELIGIBILITY, HOW TO GET VACCINATED, AND WHAT DOCUMENTATION YOU WILL NEED TO PROVIDE TO RECEIVE YOUR VACCINE. PLEASE PROVIDE THIS INFORMATION TO YOUR EMPLOYEES. Help us serve you better by completing a short survey.Visit our website at v._vyw publichealth lacounty qov/eh. A 1 EHS Signature Page 1 oil PLAN CHECK OFFICIAL INSPECTION REPORT DATE 06/14/2021 EHS ADRINE IBRANYAN PLAN CHECK NUMBER SR0198943 PROGRAM ELEMENT 1703-RESTAURANT(2,000-3,999 SF) OWNER/REQUESTER JENNY XU, DESIGNER DBA ANKAA LIVE PLAZA-BAR ADDRESS 1020 S BALDWIN AVE,ARCADIA, CA 91006 DISCLOSURES It is a misdemeanor violation to begin operation without a valid Public Health Permit/License.The Public Health Permit/License • will be issued by the Los Angeles County Department of Public Health Environmental Health Division(DPH-EH)Plan Check Program at the job site following final inspection and approval by all applicable agencies. Remodeled areas of an existing food facility/establishment must obtain a final inspection and approval from all applicable enforcement agencies prior to use. Any future alteration,construction,building,renovation,repair,change of equipment,change of the operation of a food facility/establishment or change of menu may require plans to be submitted to the DPH-EH Plan Check Program. Additional approvals may be required from other enforcement agencies. It is improper and illegal for any County officer,employee or inspector to solicit bribes,gifts or gratuities in connection with performing their official duties. Improper solicitations include requests for anything of value such as cash,discounts,free services,paid travel or entertainment,or tangible items such as food or beverages. Any attempt by a County employee to solicit bribes,gifts or gratuities for any reason should be reported immediately to either the County manager responsible for supervising the employee or the Fraud Hotline at(800)544-6861 or www.lacountyfraud.org. YOU MAY REMAIN ANONYMOUS Public Health Permit/License: A separate fee is required for the Public Health Permit/License.A billing statement will be sent to the permit/license holder annually by the DPH-EH. The fee is required to be paid to perform or carry on,conduct or engage in any mobile food facility listed in Los Angeles County Code,Title 8,Section 8.04.720. State and Local Licenses and Permits: Contact the State of California and your local city hall regarding additional license and permit requirements. Restrooms: Customer may use restroom facilities if they are located in a customer area.Customers may not enter the food preparation area,food storage area,or the utensils washing/storage areas in order to access the restrooms.All food,utensils and equipment must be protected from contamination. Routine Inspection:The DPH-EH conducts routine inspections of all food facilities in Los Angeles County. Following the issuance of your Public Health Permit by the Plan Check Program,an Environmental Health Specialist from your local district will conduct an inspection of your facility. If your Business is located in a city that has adopted the grading ordinance,the inspector will post a grade or score card at your facility. Grade/Score cards are not issued by the Plan Check Program. Help us serve you better by completing a short survey.Visit our website at www.oublichealth.lacountv.aov/eh. A Al EHS Signature Page 2 of 2 ,.•..- City of Arcadia, CA Permit NO. ROOF-20-0650 Development Services Department Permit Type:Roof 240 West Huntington Drive,Post Office Box 60021 r Arcadia,CA 91066-6021 Work Classification:Reroof-Commercial (626)574-5416 Permit Status:Issued ARC:ADIA Issue Date:05/05/20201 Expiration: , Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 11020 S BALDWIN AVE Arcadia,CA 91007-7234 5778006010 Contacts SOUTH LAKE 12 LLC AND CYTS USA LLC Owner SUNNY ROOFING&CONSTRUCTION* Contractor 153 Hudson,Pasadena,CA 910014992 1921 S FIFTH AVE,LOS ANGELES,CA 90018 (213)254-7909 858962 -es I I Description:T/O AND REROOF COMMERCAL BUILDING WITH Valuation: $ 130,000.00 Tenant BUILT UP ROOFING SYSTEM,CRRC COMPLIANT,ENERGY COATING.LT Total Sq Feet: 0.00 Plan Check# Plan# ti Fees Amount Payments Amount Paid Building Issuing Fee $47.01 Total Fees $1,484.26 Building Permit Fees $1,431.00 Cash/Receipt#REC-04401-20 $1,484.26 Solid Waste Management Fee $6.25 Amount Due: $0.00 Total: $1,484.26 - -...s 6-1-2-D 1Yz& g pec p tX(q; c? Ch�- Dar_120-r r`'' �D� CALLS FOR INSPECTIONS i (�.,^) Request for inspection by telephone at 626-574-5450. Leave a message requesting the address,timeframe and what inspection item is needed. hN -Z3' Zo ----- This 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. Gon�� I� May 05, 2020 Issued By: Date ------------- May 05,2020 Page 1 of 1 111 -111 .. 1 PERMIT/PLAN REVIEW APPLICATION �3 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 4 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 0 I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less) 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit is issued,I shall Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers' penalty of not more than five hundred dollars($500)): compensation Laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall ❑I, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions. compensation,will do the work,and the structure is not intended or offered for sale(Section 7044,Business and Professions Code:The Contractors License Date Signature Law does not apply to an owner of property who builds or improves thereon, or who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful, sale.If,however,the building or improvement is sold within one(1)year of and shall subject an 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 ' k1 4g.�� I/ PERMIT/PLAN REVIEW APPLICATION 1� // Development Services Department, 240 � 1West Huntington Drive, Post Office Box 60021 Arcadia,CA 91066-6021, (626)574-5416, Fax (626)447-9173 -. 1.---- .--- ONLINE PERMIT/PLAN REVIEW APPLIC TiON ARC.ADIA 6 `9 2.0 'v ,/� Job Site Address: � 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'1000,of Division 3 of the Business and Professions Code,and my license is in full force and effect. El 1 have and will maintain a certificate of consent to self-insure for workers' License Class C 39 License No. 868962 Exp. Date 10/2020 compensation, as provided for by Section 3700 of the Labor Code. for the \;2 performance of the work for which this permit is issued. Signature of Contractor f OWNER-BUILDER DECLARATION ®1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code.for the performance of the work for which this permit El I hereby affirm under penalty of perjury that I am exempt from the Contractors is issued.My workers'compensation insurance carrier and policy numbers are: License Law for the following reason(Section 7031.5.Business and Professions Code.Any city or county which requires a permit to construct.alter,improve, Carrier stats Fund demolish.or repair any structure,prior to its issuance.also required the applicant 1833650 for such permit to file a signed statement that he or she is licensed pursuant to the Policy Number 'This section need not provisions of the Contractors License Law(Chapter 9(commencing with Section 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(5500)): 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 ElI, as owner of the property, or my employees with wages as their sole iotthwtth comply with those provisions compensation,will do the work,and the structure is not intended or offered for 5/5/2020 sale(Section 7044, Business and Professions Code:The Contractors License Date Signature Law does not apply to an owner of property who huilds 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. riI, 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 fur 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 Date5/5/2020 Si nature Lender's Address IMPORTAVi: APPLICATION iS HEREBY MADE it) THE BUILDING OFFICIAL TOR A PERMIT Si:BJEt2T TO THE CONDITIONS AND RESTRICTIONS SEI FORTH ON THIS APPLICATION AND THE FOLLOWING: 1. The City's approved plans and permit inspection card must remain on the job sue 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 Woongpyo chris hong Titie president 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 \CD----Th 1 -._ __ Date 5/5/2020 .•. City of Arcadia, CA Permit NO. Demo-19-1883 Development Services Department Permit Type:Demolition 240 West Huntington Drive,Post Office Box 60021 Arcadia,CA 91066-6021 Work Classification:Demo-Commercial (626)574-5416 Permit Status:Issued ARCADIA Issue Date:09/16/2019 Expiration: 03/14/2020 ti Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number [ ozoS Baldwin AVE Arcadia,CA 57780060101 � Contacts ANKAA LIVE PLAZA,LLC Owner KING SAN WONG* Contractor 439 S ALMANSOR,ALHAMBRA,CA 91801 (626)715-1485 (626)780-8366 782163 Description:INTERIOR DEMO ONLY FOR ANKAA LIVE ARCADE Valuation: $ 500.00 Tenant Total Sq Feet: 0.00 Plan Check# Plan# - 1 Fees Amount Payments Amount Paid Demo-Sewer Cap and/or Cesspool Fill $16.48 Total Fees $117.75 Demolition Permit Issuance Fee $47.01 Cash/Receipt#REC-02509-19 $117.75 Plumbing Permit Issuance Fee $47.01 Amount Due: $0.00 Solid Waste Management Fee $6.25 Solid Waste Management Fee 2 $1.00 Total: $117.75 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. r- 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. September 16, 2019 Issued By: Date September 16,2019 Page 1 of 1 A.: PERMIT/PLAN REVIEW APPLICATION °:::„„.Ifita•....- m* Development Services Department,240 West Huntington Drive,Post Office Box 60021 4Nalty O 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 icense is in full force and effect. I have and will maintain a certificate of consent to self-insure for workers' License Class License Not I 6 3 Exp. Date-2/g( 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. ER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section OWNER-BUILDER R B 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 0 I herebWN License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less) 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt there from and the basis for the alleged exemption. Any violation of I certify that in the performance of the work for which this permit is issued,I shall Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers' penalty of not more than five hundred dollars($500)): compensation Laws of California,and agree that if I should become subject to the workers'compensation provisions of Se 'on 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 1 /' — I Qj sale(Section 7044,Business and Professions Code:The Contractors License Date�� V l 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. 0 I, as owner of the property, am exclusively contracting with licensed 1 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. are .jam �-3,1-P1tINT N Title <_G.0 j✓Ccs L7 WC,, 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 co y with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of Arcadia toe er upon the above-mentioned property for inspection purposes. ignature Date ! (6.-- I City of Arcadia, CA Permit NO. FIRE-20-0922 Development Services Department Permit Type:Fire 240 West Huntington Drive,Post Office Box 60021 Arcadia,CA 91066-6021 Work Classification:Fire Suppression (626)574-5416 Permit Status:Issued ARCADIA Issue Date:07/01/20201 Expiration: 07/01/2021 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1020 S Baldwin AVE Arcadia,CA 91007-7234 5778006010 Contacts SOUTH LAKE 12 LLC AND CYTS USA LLC Owner United Fire Service,Inc* Contractor 153 Hudson,Pasadena,CA 910014992 8755 Remmet AVE B,Canoga Park,CA 91304 (818)346-2499 822177 Description: 16 FIRE NOZZLES FOR ARCADE Valuation: $ 4,050.00 Tenant Total Sq Feet: 0.00 Plan Check# Plan# ti Fees Amount Payments Amount Paid Fire Extinguishing System Plan Check $560.00 Total Fees $761.76 Fire Issuance $47.01 Cash/Receipt#REC-04870-20 $761.76 Fire Permit Fees $153.75 Solid Waste Management Fee 2 $1.00 Amount Due: $0.00 Total: $761.76 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. rJ July 01, 2020 Issued By: Date July 01,2020 Page 1 of 1 IA' cpooRn4e'e 0 ! htl, PERMIT/PLAN REVIEW APPLICATION ,�., wa el t�' Development Services Department,240 West Huntington Drive,Post Office Box 60021 0,,N,..... � .e Arcadia,CA 91066-6021,(626)574-5416,Fax(626)447-9173 00°alit etH 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. ❑ 1 have and will maintain a certificate of consent to self-insure for workers' License Class License No. _ Exp. Date compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Signature of Contractor LiI have and will maintain workers'compensation insurance,as required by Section OWNER-BUILDER DECLARATION ❑ I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less) 7000)of Division 3 of the Business and Professions Code)or that he or she is ❑ 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 LiI, 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 PENT 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 City of Arcadia, CA Permit NO. FIRE-20-0713 Development Services Department Permit Type:Fire 240 West Huntington Drive,Post Office Box 60021 Arcadia,CA 91066-6021 Work Classification:Fire Sprinkler (626)574-5416 Permit Status:Issued _A RCAD IA Issue Date:06/02/2020 Expiration: 06/02/2021 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1020 5 Baldwin AVE Arcadia,CA 91007-7234 5778006010 Contacts SOUTH LAKE 12 LLC AND CYTS USA LLC Owner F&H Fire Protection* Contractor 153 Hudson,Pasadena,CA 910014992 1119 Westminster AVE,Alhambra,CA 91803 (626)262-3876 584319 Description:FIRE SPRINKS FOR TI 565 HEADS Valuation: $ 72,000.00 Tenant Total Sq Feet: 0.00 Plan Check#20-713 Plan# Fees Amount Payments Amount Paid Fire Issuance $47 01 Total Fees $2,018.21 Fire Permit Fees 5990.20 Cash/Receipt U REC-04512-20 $980.00 Solid Waste Management Fee 2 51.00 Cash/Receipt 1$REC-04603-20 $1,038.21 Sprinkler Heads $980.00 Amount Due: $0.00 Total: $2,018.21 , 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. rnr,ii[5)q 779 ✓ U'u li 'u June 02, 2020 Issued By: Date June 02,2020 Page 1 of 1 a9•4 PERMIT/PLAN REVIEW APPLICATION E >rb' 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 • performance of the work for which this permit is issued. Signature of Contractor OWNER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section 0 I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit License law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less) 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit is issued,I shall Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers' penalty of not more than five hundred dollars($500)): compensation Laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall ❑I, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions. compensation,will do the work,and the structure is not intended or offered for sale(Section 7044,Business and Professions Code:The Contractors License Date Signature Law does not apply to an owner of property who builds or improves thereon, or who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful, sale.If,however,the building or improvement is sold within one(1)year of and shall subject an 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: 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 • , City of Arcadia, CA Permit NO. FIRE-20-0816 • Development Services Department Permit Type:Fire 240 West Huntington Drive,Post Office Box 60021 Arcadia,CA 91066-6021 Work Classification:Fire Alarm (626)574-5416 Permit Status:Issued ARCADIA Issue Date:06/10/2020 Expiration: 06/10/2021 Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number 1020 S BALDWIN AVE Arcadia, CA 91007-7234 5778006010 11 Contacts SOUTH LAKE 12 LLC AND CYTS USA LLC Owner American Dynamic Services, Inc. Contractor 153 Hudson,Pasadena,CA 910014992 2275 Huntington,San Marino,CA 91108 (626)446-1199 922849 -sir Description:FIRE ALARMS FOR ARCADE 81 DEVICES Valuation: $ 26,000.00 [Tenant mm— Total Sq Feet: 0.00 Plan Check#20-816 Plan fterli lle,) t ti • Fees Amount Payments Amount Paid Fire Alarm Plan Check $980.00 Total Fees $1,528.51 Fire Issuance $47.01 Cash/Receipt#REC-04669-20 $1,528.51 Fire Permit Fees $500.50 Solid Waste Management Fee 2 $1.00 Amount Due: $0.00 • ti Total: $1,528.51 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. O r lVvhi;J 5L L L'J June 10, 2020 Issued By: Date June 10,2020 Page 1 of 1 r PERMIT/PLAN REVIEW APPLICATION iti,c\E� Development Services Department, 240 West Huntington Drive, Post Office Box 60021 00UIq o'N 4, 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 performance of the work for which this permit is issued. Signature of Contractor OWNER-BUILDER DECLARATION 0 I have and will maintain workers'compensation insurance,as required by Section 0 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 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, 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. 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. 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 City of i A Los Angeles Uniform Code Program Uniform Procedure I-7: Special Inspections Special Inspection Report • DISCREPANCY x CONFORMANCE _ I Al;discrepancies shall be brought to the immediate attention of If work conforms to approved design and code requirements,submit � the Contractor for correction. If correctens are not made in a this report to Building Department and copies to Contractor,Engineer/ timely manner,this report shall be used a a discrepancy netice. Architect of record and Owner no later than the business following I Submit the original to Building Department and copies to the conclusion of the special Inspection, For inspections greater than Contractor,Engineer/Architect of record and Owner. , days duradon1subltut a conformance report at;east once every week. This Is a: •A Progress Report • Final Report Report No. _1 Page No. _l_of_1__ ` Project Address: C cz pticrr of PrGject 020 s . �C r.a'✓ r i-) -(�' (_-iiGirj�G r'+ e41- gmse,laa. /7J' Permit Number: (.l_ L4.14 � •- 1 ssr s C. j 44 p(.4- ds,. ArihltecVErg(neer or rd: Contractor. Full Name of ����/ate/ �-• Special Inspection: City Registration Number Company: Phone Number Huan Van Bui P013049 �'ar VanBui Inspection 714-345-8266 / 2�'�.L ic.c Type of Inspection: a Reinforced Concrete a Structural Masonry a Piling, Piers &Caissons a Smoke Control a Prestressed/Post-tensioned o Bolts in Concrete/Masonry a Excavation and Fills D Energy Compliance a Shotcrete/Gunite a Structural Welding a Spray-Applied Fire Proofing a Testing Reports a Insulating Concrete/Gyperete a High Strength Bolting a-Other ,Pirt)--..7, Time Time Date Arrived Departed Description and Location of Work Inspected 4 3/ia 9:00f 1qp'1q'240 t'. o ),�, •►►Gip, lr—.�/ //X_ a (3g) .sig !141g 41( ,p. , %�7751/Z ,,) r/4`(4 146-g•/, ¢ ',a'c -"fN,Gees e wA-41 2 c' " / fG , /-074 c, oe•5 w( gear IL( c-7142-or.,- Remarks: -7142-oxrRemarks: i, 07=-Grs K'/ i& . r Afr..i1�.�ciC /a `i-, 2 -i�, ic—c._ —mss , Cy - //zg/zaz 2 I HEREBY DECLARE THAT THE FOLLO'MNG IS TRUE TO THE BEST OF MY KNOWLEDGE: '• :AM,OR MY COMPANY IS,RETAINED BY THE OWNER OR THE ARCHITECT/ENGINEa OF RECORD TO PROVIDE SPECIAL IUSPECTICN FOR THE WORK COVERED IN THIS REPORT. 2. 1 HAVE PERFORMED THE REQUIRED INSPECTION DURING THE TIME PERIOD AS STATED ABOVE. 3. THE WORK COVERED IN THIS REPORT IS IN CONFORMANCE TO THE APPROVED PUNS,SPECIFICATIONS ANO APPLICATICN WORKMANSHIP PROYtSIONS CF THE CODE,EXCEPT AS INDICATED OTHERWISE. Signature: -ii— . rarer /1,---•1. Date ///(1' /zTrD Huan 'Ian Buf, Deputy Inspector