FOR USE CITY OF BEVERLY HILLS Plan Review Permit Application DECLARATIONS LICENSED DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of 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 Lic. No. Signature Date OWNER-BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State 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 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for the purpose of sale). l, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the project with a contractor(s) licensed pursuant to the Contractors' State License Law.) I am exempt under Sec. Bus. and Prof. Code, for this reason: Owner Signature Date DECLARATION I am exempt from contractors? licensing laws under Sec. 7051, Bus. and Prof. Code for this reason: I am acting solely in my professional capacity. Signature Date COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. [3 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 is issued. My workers' compensation insurance carrier and policy number are: Policy No. Company Date Signature CERTIFICATE OF EXEMPTION FROM COMPENSATION INSURANCE I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' 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 forthwith comply with those provisions. Signature Date WARNING: FAILURE TO SECURE COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND FEES. . CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. Code). Lender's Name and Address ASBESTOS DECLARATION (DEMOLITION) (Health and Safety Sec. 19827.5) Please mark the appropriate box and sign below: The building to be demolished has been surveyed and it El does does not contain asbestos. A copy of the notification form as required by SCAQMD Rule 1403 is enclosed. The building contained asbestos and the abatement work has been completed. A copy of the completion certificate is enclosed. Owner or Agent Date I certify that have read this application and state that the above information is correct. I agree to comply with_all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this City and County to enter upon the above-mentioned property for inspection purposes. Signature of Applicant or Agent Print Name Date FOR CUSTOMER USE CITY OF BEVERLY HILLS Plan Review Permit Application [3 BUILDING SHORING CERTIFICATE OF COMPLETION FRONT YARD PAVING ELECTRICAL CERTIFICATE OF OCCUPANCY FENCE WALL MECHANICAL [3 LOW VOLTAGE [j SIGNAGE PLUMBING CONSTRUCTION PARKING SANDBLASTING SOLAR PANEL WATER EFFICIENT LANDSCAPING [j GRADING FIRE SPRINKLER DEMOLITION SECOND UNIT FIRE ALARM ROOFING [j ELECTRIC VEHICLE [j ARTIFICIAL TURF ASBESTOS ABATEMENT PROJECTA ESS Fax 4&sz WT 670210 FLOOR VALUATI MATERIALS) AREA OF WORK (ESTIMATED so FT.) (F. DESCRIPTION OF WORK #4wa fame/M6 My] dodf/ 414% ?an/LL gab? 34M afgmm?/ ADDRESS CITY OFFICE CELL PHONE . ELM HZZ, E-MAILIREQUIRED) any?? (6), f?a?f??I/Cv/I?m C-6n/) PROPERTY EI . I ADDRERs I I I?go?f?? V51 O46 WI Pa. CITY I STATE ZIP . MW b7 HIM I No. I HOME PHONE CELL PHONE CONTRACTO EQU ED IF AT ON IS 8500 ETAPPLICANT ?lm ADDRESS ZIP I I STATE 62W 58 Lin/(lo 144/9715? . ARCHITECT APPLICANT ADDRESS CITY STATE ZIP OFFICE PHONE STATE LICENSE EXPIR. E-MAIL ENGINEER APPLICANT ADDRESS CITY OFFICE PHONE EMAIL (REQUIRED) CITY OF BEVERLY HILLS Plan Review Permit Worksheet REQUIRED FEES FOR STAFF USE - PLAN REVIEW PLAN REVIEW ENERGY FEE PLANNING PLAN REVIEW LID PLAN REVIEW 831605 PLAN REVIEW PLAN REVIEW El GRADING PLAN REVIEW SUSMP PLAN REVIEW (3 PLAN REVIEW HILLSIDE PLAN REVIEW [3 CONCEPT REVIEW OTHER GENERAL PLAN LONG RANGE PLANNING FEE OVER THE COUNTER PLANNING REVIEW APPLIES TO MFR COMMERCIAL PI EPLAN REVIEW (HRS) RDSHIP EXEMPTION FIRE REVIEW CHNOLOGY FEE REVIEW IZI CIVIL ENGINEERING SFR REVIEW CIVIL ENGINEERING MFR REVIEW [3 CIVIL ENGINEERING COMMERCIAL REVIEW El TRANSPDIVISION APPLICATION REVIEW [3 TRANSP. 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EDUCATION HEAVY HAULING TROUSDALE CONST. VEHICLE TRAFFIC FEE [j CHANGE OF CONTRACTOR INVESTIGATION FEE 6h. BEVERLI HILLS 2 FOR STAFF USE CITY OF BEVERLY HILLS Plan Review I Permit Worksheet PC PC SUBMITTAL EXPEDITED PC PERMIT INFORMATION COMBINATION WIZARD EBUILDING :1 FY. PAVING 821% 0 ESHORING E) (E) ELECTRICAL SIGNAGE 5 MECHANICAL ROOFING PROJECT ADDRESS 891 PLUMBING ELECTRIC VEHICLE PANEL EFF. 4' (LO 6 El FIRE SPRINKLER :1 SANDBLASTING FIRE ALARM GRADING UNIT FLOOR VALUATION DEMOLITION :1 SECOND UNIT 2 POOLJSPA ASBESTOS ARTIFICIAL TURF Cl CONST. PARKING DESCRIPTION OF WORK: EW- Afin?b MC LE) 2 917/7 5% LAND STRUCTURE I OCCUPANCY INFORMATION USE I LOT AREA 1 4'4 200 OCC. GROUP I PAD AREA SLOPE AREA CONSTRUCTION TYPE I ALLOWABLE FLOOR 0! 7 I AREQN SITE (F.A.R.) 35 6 HEIGHT I EXISTING BUILDING AREA . (NOT INCLUDING GARAGE) I I (2/610 STORIES I FLOOR AREA ADDED ROOFING I NEW BUILDING AREA 1 (NOT ZONING I GARAGE AREA TI 5.0 OF UNITS- A 7 20 1 '1 BEDROOMS 5 I OTHER BUILDING AREAS PARKING REOUIRED 4. OF BUILDINGS ON SITE I TPARKING PROVIDED 4 TOTAL FLOOR AREA ON SITE I I) (540 PLANS ON FILE CAL GREEN COMPLIANCE SETBACK FRONT REAR SIDE 1 SIDE 2 YES No T4 T2 ACTUAL FIRE SPRINKLERS YES NO El REQUIRED F.S. TO SUB. FOR 1-HR YES NO GRADING SANDBLASTING SIGNAGE SOILS REPORT ON FILE: El WET SANDBLAST FILL: START DATE WORDING ON-SITE IMPORT END DATE NUMBER OF CUBIC YARDS: REPORT It DATE MATERIALS Elli: LOCATION OF SIGN CONSTRUCTION SIGNS NUMBER TOTAL AREA ROUTE OF TRAVEL NOT OVER 10 SQ FT NOT OVER 20 SQ FT OVER 20 SQ FT OTHER SIGNS STAFF REMARKS APPROVALS (a Mvoo m5 PLANNING DATE BUILDING DATE AND SAFETY CIVIL DATE ENGINEERING FIRE DATE DEPARTMENT WATER DATE TRANSPORTATION DATE PARKS AND DATE RECREATION