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Permit No. 1059001323201A01 11,: SAP1 BERNARDINO COUNTY—EPWA/LANDSAGEMENT DEPT • OFFICE OF BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR 105 90 01323 201A 01 STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL DATE 05/24/90 ISSUE DATE 05/24/90 I PG 1 OF 1 PARCEL NUMBER 1000-181-10-0000 PROPOSED USE: ADD.BEDROOM S.F.FOR RESIDENCE CURRENT USE: VACANT 9781TRA BLK LOT SEC NG ACTIVITY : CT 1000 007 I NE36 103S 09W I PRCL 00AP I PRCL COMMUNITY PLANL828 ZONE/LAND USE DISTRICT GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS CH/PD LOT DIMENSION IRREGULAR CONST TYPE VN APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER #BLDGS ON LOT GROUP R3 DYKIER, PAUL 122 VIKING AVE *PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 12-162 BREA CA 92621-0000 STD PLAN/ICBO FHA N (714) 255 — 0429 TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER DYKIER, PAUL 1 217 1.00 217.00 122 VIKING AVE BREA CA 92621-0000 CALC. VALU 9,765.00 I ADJUSTED AREA 217 (714) 255 — 0429 ITEM CNT DESCRIPTION DETAIL TOTALS JOB SITE ADDRESS RESIDENTIAL CONSTRU 109.37 16213 CANYON HILLS RD TOTAL AMOUNT 109.37 CHINO HILLS CA 91709-0000 CROSS STREET SPRING CREEK WAY INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER DTV. OF ).ND. SAFETY PERMIT: MINIMUM SETBACK DISTANCES 55 FRNT SETBACK/CENTRLINE CANYON HILLS RD R/W 66 20 REAR SETBACK/PROP LINE 10 SIDE SETBACK/PROP LINE 10 SIDE SETBACK/PROP LINE MECHANICAL EQUIP NOT PERMITTED IN REQUIRED SIDE SETBACKS V NO. STORIES NO. DWELLING NO. BEDROOMS FLOOR € _ k9i 6'' pt 1 UNITS 1 4 CONCRETE EXT. WALLS INT. WALLSCEILING8 LET N4 STUCCO SHEETROCK SHEETROCK , jp ROOF HEATING FIREPLACES S an ---42f TILE NATURAL GAS (METAL IMASRYWATER PUBLIC (PRIVATESEWER ( MI0030EPTHI S 060100I1000EI NENEWEPAIR COMMENTS AMT WAIVED .00 AMT PAID 109.37 PAYOR NAME: DUKIER ENGINEERING PAID 05/24/90 RECEIPT 2178 EMPL: FLETS, DEBORAH PAID BY : CHECK NBR : 160 ICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM THAT I AM LICENSED UNDER T�ROVISIONS OF CHAPTER 9 (COMMENCING WITH SE. 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LICENSE NUMBER CONTRACTOR DATE OWNER-BUILDER DECLARATION I HEREBY AFFIRM THAT I AM EXEMPT FROM THE CONTRACTORS 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, DEMOLISH OR REPAIR ANY STRUCTyRE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT 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 7000)0E DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM 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 ($5001.1: ❑ 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(SECTION 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH 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). ❑ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS 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 CONTRACTORIS) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW). ❑ I AM EXEMPT UNDER SEC. B. AND P. C. FOR THIS REASON OWNER DATF WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM THAT I HAVE A CERTIFICATE OF CONSENT TO SELF-INSURE OR A CERTIFICATE OF WORKERS'COMPENSATION INSURANCE OR A CERTIFIED COPY THEREOF (SEC. 3800, LAB.C.). POLICY NO. - COMPANY ❑ CERTIFIED COPY IS HEREBY FURNISHED ❑ CERTIFIED COPY IS FILED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT APPLICANT DATF CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($1001 OR LESS). 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. APPLICANT DATF NOTICE TO APPLICANT: IF,AFTER MAKING THIS CERTIFICATE OF EXEMPTION,YOU SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF THE LABOR CODE, YOU MUST FORTHWITH COMPLY WITH SUCH PROVISIONS OR THIS PERMIT SHALL BE DEEMED REVOKED. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). LENDER'S NAME LENDER'S ADDRESS DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION THE CALIFORNIA HEALTH AND SAFETY CODE REQUIRES A DIVISION OF INDUSTRIAL SAFETY PERMIT AS A PREREQUISITE TO PERMIT ISSUANCE UNLESS THE APPLICANT SIGNS ONE OF THE CERTIFICATES BELOW. ❑ I CERTIFY THAT NO EXCAVATION 5 FEET OR MORE FEET IN DEPTH, INTO WHICH A PERSON IS REQUIRED TO DESCEND,WILL BE MADE IN CONNECTION WITH WORK AUTHORIZED BY THIS PERMIT,AND THAT NO BUILDING,STRUCTURE,SCAFFOLDING,FALSEWORK,OR DEMOLITION OR DISMANTLING THEREOF,WILL BE MORE THAN 36 FEET HIGH ❑ AS OWNER/BUILDER I WILL NOT EMPLOY ANYONE TO DO WORK WHICH WOULD REQUIRE A PERMIT FROM THE DIVISION OF INDUSTRIAL SAFETY,AS NOTED ABOVE UNLESS SUCH PERSON HAS A PERMIT FROM THAT DIVISION. DIVISION OF INDUSTRIAL SAFETY PERMIT NUMBER I CERTIFY THAT I 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 COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. SIGNATURE OF APPLICANT OR AGENT DATE EXPIRATION AND REFUND NOTICE APPLICATIONS FOR WHICH NO PERMIT IS ISSUED WITHIN 180 DAYS FROM THE DATE OF APPLICATION SHALL EXPIRE.PERMITS SHALL EXPIRE IF WORK DOES NOT COMMENCE WITHIN 180 DAYS OF ISSUANCE OF SUCH PERMIT OR IF THE WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS.FEES PAID ARE NOT REFUNDABLE AFTER 180 DAYS FROM DATE OF PAYMENT, EXCEPT FOR ERRORS IN ACCEPTANCE WHICH MAY BE REFUNDABLE UP TO ONE YEAR FROM DATE OF PAYMENT. ALL FEES PAID MAY NOT BE REFUNDABLE. 12-17588-469 Rev. 10/88 Owner Name 411— Permit Num. _ INSPECTION RECORD DATE I INSPECTOR I DATE I INSPECTOR Setback Rough Plumbing Temporary Power Shower Pan Test Foundation Reinforcing Steel Stucco Mesh or Exterior Siding Excavation and Forms Insulation F.H.A. Foundation Req. Sewer Slab Grade Interceptor Ground Plumbing Septic Tank Underslab Ducts Leach Line or Seep Pit Underslab Conduit Water Service Fireplace Foundation Lath or Drywall Nailing Joists and Girders Gas Line Air Test Electrical Ground Final Energy Mid-Height Bond Beam Final Plumbing n 8-Foot Bond Beam • Final Heating/A.C. A I Final Bond Beam Final Construction " 'I Y.- Fireplace Bond Beam Final On Site Improvements .1IY ,-2,,,, of Roof Sheathing Final Off Site Improvements` 1 ✓ L/ " T Framing and Ventilation Final Dedication )(A !` Roof Covering Final Zoning tr ( I ! , Rough Heating Final Electrical U In Electrical Service and Ground Final Gas V Rough Electrical Developer Fees Paid WC (Y/N) Ind Saf (YIN) Certificate of Occupancy A , i / �, / l "7--7/ . ,;'. ,)'11(/J) . e. ,•� 4/.m.-i✓•A...... .x (� — i i ( !A/9."2-.L__ ( /1 /G.r"- .P-'3 - Ob 3 6 ? - ..le/41-->n-1 ,r, n ��,�-r-) 0......e a Tt Go 4-J . A A? r-a) • .1 t 0 – �—E. r4 T7, -4 r, rs•1 iv'V 7 U f2fl4. •-•-;40. Cy-,.....- a4-4 ... t- . �i10 J..�' "f-f�—pi p ?_ /..)• Gag ,.),T , or 2. F CI_ SEPTIC TANK GALS. /4 t 0 '72.._d a— ic:. SEEP. PIT X LEACH LINF WIDE X LONG X DEPTH OF ROCK N. . giT Din , Y, Ate`; � 'i . w a• /dFics'a.-}1.-/' S. Inspector's Signature and Initials �/� 12-17589-489 Rev.3/88