HomeMy WebLinkAboutTI-19-2330 I z
a City of Arcadia, CA Permit NO TI-19-2330
i Development Services Department , i , Permit Type'Tenant,.Improvement
s.. r ;•. 240 West Huntington Drive,Post Office Box 60021 `s l i !/ j '
-$ Arcadia,CA 91066-6021 "'i I ,, 1 l 4 ; ,Work Classification:Tenant Improvement
r° :;,--,f
t (626)574-5416 Permit Status:Issued
.AI.cADJA Issue Date 11/21/2019.,I Expiration:
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
468 E Santa Clara ST Arcadia,CA 91006-7229 5773009081
s= _•�,_u ,_,h. ._W ��.� ....
Contacts
FIFTH AVENUE GROUP LLC Owner THE HALE CORPORATION Applicant
488 E SANTA CLARA ST 513 5 MYRTLE AVE,MONROVIA,91016 ii
(626)358-4523
.
Description:T.I.FOR CHLA includes MEP's 1 Valuation: $ 96,800.00 Tenant CHLA
Total Sq Feet: 0.00 Plan Check#19-2330 Plan#179
Fees Amount Payments Amount Paid
Accessibility Plan Check $116.90 Total Fees $4,006.33
Accessiblity Building Permit $119.90 Cash/Receipt#REC-03111-19 $1,493.95
Add/Alter Ducts $328.02 Cash/Receipt#REC-03149-19 $2,512.38
Building Issuing Fee $47.01
Building Permit Fees $1,198.95 Amount Due: $0.00
Building Plan Review Fee $779.32
Cal Green Plan Check $77 94 �� ' .23•Zo
Chk. $280.00 i :1 iCOWPETE �1�a
Electrical Permit Issuance Fee $47.01
i r
Energy Plan Review Fee $239.79
Fire Final Occupancy Fee $200.00 CALLS FOR INSPECTIONS
Green Building Standard $4.00 Request for inspection by telephone at 626-574-5450. Leave a message
Lavatories $211.36 requesting the address,timeframe and what inspection item is needed.
Light Fixtures $69.70
Mechanical Permit Issuance Fee $47.01
Outlets-Receptacles&Switches $142.84 This permit/plan review expires by time limitation and becomes null and
Plumbing Permit Issuance Fee $47.01 void if the work authorized by the permit is not commenced within 180 days
Solid Waste Management Fee $6.25 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
Solid Waste Management Fee 2 $1.00 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
Solid Waste Management Fee 2 $1.00 Arcadia building inspector for a period of 180 consecutive days.
Total: $4,006.33
I
C.-. ---..„
November 21, 2019
Issued By: Date
I
November 21,2019 Page 1 of 1
' II - Z330 :� _ -
•
NOTES
Building Inspections Date Insp. Plumbing Inspections Date Insp. L f(.8 C - 3,,s,r,1.1,,, C L,kruls
100. Setbacks 210. Under fir./bldg.drain 9.M.to 43------
101. Rough grade 211. Copper underslab
102. Figs.&forms 212. Rough plumbing 7•3o•Zo -,----+
103. Pre-slab 213. Rough gas /�,� a.�G�w�s, uft. �W'4/1
104. Floor joists 214. Shower pan 1'feAl E t�/)/. Off Au^a e g6t-sE(2) `f>-l°
105. Steel 215. Water heatrains M e. L 6 w�4 P J& (Z
u�C1•�
106. Grout lift 216. Roof drains
P 1 , r ,_' P,� Q)148•20 l-
107. Shear nailing 217. Building sewer r
108. Diaph nailing 218. Water service [fy`,go J(27 6-•4,t,L tO f(Z). --
109. Roof nailing 219. Final gas /�
110. Framing .7.3o•1A 220. Fixtures f.//'70 /"L uv►q f/,✓tj, Ci-Ec-, p /'L2"i. .'j,
111. Occ./Area Sept.Wall 221. Final plumbing 1.2 3 ?� �Y-
/r✓� v r v/Gr .e-kr_ a At )&um/.
st.
112. Sound walls 222. Sewer cap/demo.
113. T-bar•rid 8'Z ?,, c.- y/y Zo 6"41d6 V(ov r(-e eOf�.) " -------
114. Insulation-Flr. Pool Inspections Date Insp. I//S 70 fivAe-iO4---,..4.40 e P1().
115. Insulation Wall 240. Excavation/steel I/.29.z,Q r-4411r -I- Foktv/LS a-PIKI - T-‘--
116. Insulation-Ceil. 241. Rough plumbing
117. Drywall nailing &4-2-o 242. Light shell/bonding _ S/3.ZO Ulf Ad,,,er.v() -Mel-, 31f1 t,0 A1t
118. Interior lath 243. Underground conduit OPrN . � /t 2 ��►-
119. Exterior lath 244. P-trap
120. Finish grade 245. Gas line&test $:X.2, ct"Ar,<,vy 2.E'1.,F,rg.Ac.-,•.,a . Pad-)
121. Final building 9'23•20- 246. Fence,gates&signs
122. Final demo/lot clear 247. Pool heater c r t-6�A+^ fi 2`3/rof r, (o ra' ` -_
• 248. Final electric 5.Z%)• 2L /-..S 1J C J) c,f L-L+ rr\SJli'A'rl
Electrical Inspections Date Insp. 249. Final•lumbing
150. Power pole 250. Pool cover C Per" ��
151. Sales lot lighting • 251. Pool final S'' € - ' A/G.,*t,r_ CPt(k5F El)
152. Underground conduit
153. Underslab conduit Reroof Inspections I Date I Insp. �'�l j �6��, �7x IV �Sr �rf�G .
154. UFER ground 270. Pre-reroof insp. 7-ft..20 P4 plL fe-D v"-(10-1
C-c
155. Water ground 271. Roof framing PA-kW- Z • ' '''---
156. Rough electrical 7 30-a3 s 272. Sheathing nailing - /
157. Fixtures g'Zo•2i-_ 273. Final reroof 1)•2 •Zo Or P/AM-0{r,v4 42(3) /Tim+
158. G.F.C.I.
159. E•it.bondin• Sign Inspections I Date I Insp. S►",KS &. rinrht- Qr(h5 • dtppao✓r=7) Tc,
160. Service panel 280. Setback/overhang PoJIL 5/.44 711 'rvCpkiS
161. Final electric 9 23•Zo 281. Footing -30 n
282. Conduit/wirin•
Mechanical Inspections ' Date Insp. 283. Disconnect rN csiortL.s of v,4-1.- Pg'�
180. Venting/flue 284. Final sign $.l'f• A,•Ii,sa,%-- NA-1%.-,rya. are
181. Furnace/A.C.
182. Rouch HVAC Miscellaneous Insp. I Date I Insp. _
183. Fire dampers 290. Fire alarm
184. Furnace compartment 291. Underground supply
185. Combustion air 292. Fire sprinklers
186. Smoke detectors 293. Monitor system
187. Metal F.P.rough 294. Hood dry chem.
188. Compressor setback 295. Final
189. Commercial hood i
190. Duct shaft Sewers&Offsite Insp. I Date I Insp.
191. Final mechanical ' - .3'2o 300. Lateral(main to PI)
301. Saddle/Y
Block Wall Inspections ` Date Insp. 302. Cess•ool filled
200. Footings 303. Sidewalk _
201. Steel/rebar 304. Driveway
202. Grout lift 305. Curb replacement
203. Final wall 306. Trash bin
A of ARC
:•:incorporated
Aueurt s,1903
�r S
° MEMORANDUM
Fire Department
DATE: ' August 26, 2020
TO: BUILDING DEPARTMENT
INSPECTOR Steven Roberts
FROM: FIRE DEPARTMENT
SUBJECT: FIELD INSPECTION
ADDRESS: 468 E. Santa Clara Street
THE FOLLOWING ITEMS WERE CHECKED FOR CONFORMANCE WITH APPLICABLE FIRE
DEPARTMENT REQUIREMENTS:
TYPE OF INSPECTION DATE / INITIAL
FINAL INSPECTION
FIRE SPRINKLERS (PC# 20-575) 8-21-2020 Jill Perumean
FIRE ALARMS (PC# 20-659) 7-15-2020 Mark Krikorian
HOOD & DUCT
KNOX BOX
OCCUPANCY (PC# 19-2330) 8-21-2020 Jill Perumean
COMMENTS:
Emailed Bldg. Dept. 8-21-2020 Rita
City of Arcadia, CA
PermrtNO FIRE-20=0659
f Development Services Department ;� Permit Type•-Fire,
1r-4 240 West Huntington Drive,Post Office Box 60021 z ': , f ,• t
` i Arcadia,CA 91066-6021 j •,_' 1 &" , i, ! Work Classification,Fire Alarm
,, (626)574-5416 3 <
• " .Permit Status:"Issued
ARCADIA - Issuepate:05/11/2020. 1 Expiration:
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
468 E Santa Clara ST Arcadia,CA 91006-7229 5773009081
Contacts
FIFTH AVENUE GROUP LLC Owner USA ALARM SYSTEMS INC* Contractor
488 E SANTA CLARA ST 138 E CHESTNUT AVE, MONROVIA,CA 91016
(800)833-6068 538464
Description:FIRE ALARM SYSTEM FOR PHASE 1 OF T.I. Valuation: $ 7,000.00 Tenant
i
Total Sq Feet: 0.00 Plan Check#20-659 Plan If
`E„^affii'.'-fib. .w•.-zoxi, a^i.:as?ffi'�A 4.'S. ...'xb..>Y ..-.:x.'Ma0...m� a __�_r ��..K e +il. ,..r e:��i •
Fees Amount Payments Amount Paid
Fire Alarm Plan Check $700.00 Total Fees $935.16
Fire Issuance $47.01 Cash/Receipt#REC-04437-20 $935.16
Fire Permit Fees $187.15
Solid Waste Management Fee 2 $1.00 Amount Due: $0.00
Total: $935.16 ,
14/ COMPLETED
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.
May 11, 2020
Issued By: Date
May 11,2020 Page 1 of 1
4.; City of Arcadia, CA Permit NO. FIRE-20-0575
144 Development Services Department '. I t I ~- ,. ,' '1 Permit,Type -Fire.
). 240 West Huntington Drive,Post Office Box 60021 1 " ,1 p f • -
Arcadia,CA 91066-6021 r , ' ` 1 ; t �' �1 j I s u Work Classification Firee,Sprinkler°
(626)574-5416
Permit'Status:Issue
d
ARCADIA Issuepate:05/07/20201 Expiration: 10/13/2020
,
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
468 E Santa Clara ST Arcadia,CA 91006-7229 5773009081
1
Contacts
FIFTH AVENUE GROUP LLC Owner SINGLETON FIRE PROTECTION INC* Contractor i
488 E SANTA CLARA ST 12990 BRANDFORD ST G,ARLETA,CA 91331
(818)252-5744 667001
Description:FIRE SPRINKLERS FOR T.I. CHLA Valuation: $ 6,150.00 Tenant CHLA
Total Sq Feet: 0.00 Plan Check#20 575 Plan#
Fees Amount Payments Amount Paid
Fire Issuance $47.01 Total Fees ! $935.16
Fire Permit Fees $187.15 Cash/Receipt#REC-04282-20 $700.00
Solid Waste Management Fee 2 $1.00 Cash/Receipt#REC-04426-20 $235.16
Sprinkler Heads $700.00
Amount Due: $0.00
Total: $935.16 -
,
QOMPLETEL tii
---- 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.
May 07, 2020
Issued By: Date
May 07,2020 Page 1 of 1
\, ' ri
PERMIT/PLAN REVIEW APPLICATION' -- 4
Development Services Department, 240 West Huntington Drive, Post Office Box 60021
•
Arcadia, CA 9.1066.6021, (626)574-5416, Fax(626) 447-9173
O\iLiN.E PERMIT/PLAN REVIEW APPLICATION �t/�.
.p A:RCA DI A :Job Site Address: f' ' /� 5 /�tt
LENSED CONTRACTOR'S DECLARATION
I�hereb affirm under penalty.of perjury that I am licensed under provisions of IWORKERS'ereby irm COMPENSATION oDoC DECLARATION
hereby
Chapter 9(commencing'with Section 7000,of Division 3 of the Business and penaltyer perjury the following:
Professions Code,and lily license is in full force and effect, //� �
>✓� I have and will'maintain a certificate of consent to self-insure for workers'
License Class 6- Lice ice No.66 7'oo/- Exp., Date// 2/ compensation, as"provided for by Section 3700 of the Labor Code, for the
Signature of Contractor j .=='-" '~ performance of the work for which this permit is issued:
OOWNER-BUILDER DECLARATION aveland will maintain workers'compensation insurance,as required by Section
f 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 _i_f) 5"vnc -i#- p)/; li..sc,57.
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 I� t�{ j
(This section need not he 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 cerify that inahe performance of the work for which this permit is issued.I shall
Section 7031,5 by any applicant fur 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 MOOD: 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
El I, as o vner of the property, or my employees with wages as their sole fotthtvith 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-.-.. 5`7' ____ 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
salt If, however,the building or improvement is sold within are(I) WARNING: Failure to secure Workers'Compensation coverage is unlawful,
year of and shall subject an employer to criminal.penalties and-civil fines up to due
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
, as owner of-the property;am exclusively contracting with licensed
VI attorney'sfees.
ontractors 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
contractors)licensed pursuant to the Contractors License Law).. for the performance of the work for which this permit is issued (Section 3097,
'Civil Cod)..
J I am exempt under Section 7044,Business and Professions Code,for this reason:.
Lender's Name
Date__ __ Signature Lender's Address ..__
ItMl'OR LAN : APPI,IC V'IION-is II1.R1?uV" MMAD1. 1•t3 THE Bt1l DING OFFICIAI, FOR A PERMIT SUBJECT TO THE COND,I'1'1t/N:S AND
RESTRICTIONS INS SET FORTH 11 1)N THIS;t,l'f'l:)CA1'lt iN ,AND Thh, FOLLOWING:
I. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A-Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3 Per South Coast Air Quality Management District(AQ,MD).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:
ti or
ame t. 7rpt)rrl"7 ,!/1 Jf..( `
tNT NAME titleJ'
certify that I have read this application and state that the above information is correct and that l 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
lrcadia to enter upon-the above-mentioned property for inspection purposes.
signature -� _-.__.
_ _._... Date 5-7
of M
v~4 0,
0r ky,.9,
NON
9 PERMIT/PLAN REVIEW APPLICATION
Oki !IEEE/ a Development Services Department,240 West Huntington Drive,Post Office Box 60021
am�'ualty% Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions Code,and my license is in full force and effect. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class License No. Exp. Date compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Signature of Contractor
OWNER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section
❑ I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier
demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number
for such permit to file a signed statement that he or she is licensed pursuant to the (This section need not be completed if the permit is for one hundred dollars or less)
provisions of the Contractors License Law(Chapter 9(commencing with Section
7000)of Division 3 of the Business and Professions Code)or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): compensation Laws of California,and agree that if I should become subject to the
workers'compensation provisions of Section 3700 of the Labor Code,I shall
❑I, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions.
compensation,will do the work,and the structure is not intended or offered for
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
attomey'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 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 ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter upon the above-mentioned property for inspection purposes. i
Signature Date
of ARc.
U~ . F_ PERMIT/PLAN REVIEW APPLICATION
3 Development Services Department,240 West Huntington Drive,Post Office Box 60021
\ % Arcadia, CA 91066-6021, (626) 574-5416,Fax (626)447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions Code,and my license is in full force and effect. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class License No. Exp. Date compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Signature of Contractor
❑ I 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
❑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
U�4 ouFo Rc9d9
yy0743
PERMIT/.PLAN REVIEW APPLICATION
"lff3e.
M[mf.1f�0
o j Development Services Department,240 West Huntington Drive,Post Office Box 60021
\'.nityotn° Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia
14ENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
M I''+- eby 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 13 License No S3 8 1 Exp. Date compensation, as provided for by Section 3700 of the Labor Code, for the
Signature of Contractor =�'1 performance of the work for which this permit is issued.
OWNER-BUILDER DECLARATION ❑ I have and will maintain workers'compensation insurance,as required by Section
❑ I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier
demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number i I L�
for such permit to file a signed statement that he or she is licensed pursuant to the (This section need not a 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 i
exempt there from and the basis for the alleged exemption. Any violation .f IA 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 :bor .+ 1
❑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_ /2i/Z0I 9 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 l'HL 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 �F�A fL(� N I�Lc�� Title ►Pt —c
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 pro• for pection purposes.
Signature Li Date N Oki. �, 1`i