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Permit No. 5439 ,A` b City of L o Hills APPL .... N FOR BUILDING PERMIT Community Development 2001 Grand Avenue (ir Chino!Ills,CA 01700 Building Address:• - Proposed Use - St No. 3123 Street CHAMPION ST RESIDENCE APN 103)^V ( 3 THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT Lot (8fil Block Tract 15665 El Struct. 0 Plumb. • Applicant VAN DAELE DEV CORP ®Meth. ®Elect, 6a r St No. 2900 Street ADAMS STE C-25 Type of Project ®New 0 Alter 0 Addition City RIVERSIDE Zip Phone 354-212- 0 Repair ❑Convert. ❑Demo ❑Occupancy Permi Owner VAN DAELE DEV CORP Project 1 Location on I Size Description Property in Sq.Feet • St No. 2900 Street ADAMS STE C-25 City RIVERSIDE Zip Phone 354-212) 1. LIVABLE ( I 2538 Engr/Arch Lic No. 2. GARAGE I I 571 St No. Street 3. PORCH I 66 City Zip Phone 4. I I Contractor SAME AS ABOVE Lic No. 518827 REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION Sewer I Min. Depth I S/F/100 I Size St No. Street YES City Zip Phone Cubic Yards Excavation Fill Over Excavation City Business License License No. 2168 Expiration Date 1/31/97 Licensed Contractor's Declaration I hereby affirm that I am licensed under the 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 11 License Number crag', Dat,' Contractor SAME Address City and Zip Phone Owner Builder Declaration I hereby affirm that I am exempt from the Contractor's License Law for the following reason: ❑ I, as the owner of the property, or my employees with wages as their whole compensation, will do the work, and the structure is not intended or offered for sale. --W.._W..._.— WW.-- ❑ I,as owner of the property, am exclusively contracting with licensed contractors to construct the project. ❑ I am exempt under Sec.__,B&PC for this reason Date Initial Workers' Compensation Declaration I hereby affirm under penalty of perjury one of the following declarations: ZoningI Land Use ❑ a. I have and will maintain a certificate of consent to self-insure for workers' CH/PD,FR1 compensation as provided by Section 3700 of the Labor Code, for the performance of the wo rk for which this permit is issued. Setbacks I Model/Plan • El/b. I have and will maintain worker's compensation, as required by Section 3700 of the FY I SY I LaborCode, for the performance of the work for which this permit is issued. My worker's Ry I SSY Ii compensation Insurance carrier and policy number are: Ins. Co.: Group/Division/Type Policy No: R3/VN Exp Date: . VALUATION (This dection need not be completed if the permit is for one hundred doolars(S100)or less). $1 55,000.00 [arc. 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 PERMIT FEES 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 , th those provisions. _., // /� Electrical $279.18 Structural $1,113.74 Date /...4.---2-/-11-- _Signature_74 ie,:„.../....i,. �`�! Warning: Failure to secure workers' compensationPlumbing Grading $75.00 coverage is unlawful, and shall subject an $246.00 employer to criminal penalties and civil fines up to one hundred thousand dollars(S100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest,and attorney's fees. Mechanical $68.87 Issuance $29.00 I certify that I have read this application and state that the above information is correct. I agree to comply with all City Ordinances Geo Review ( Plan Check and state laws and hereby authorize representatives of this City Issuance Approved I Total Permit Fee to enter upo the above mentioned property for inspection 4 u ose t1 R11 7rt pose //` Z7- . Date Issued Permit Number Signn ttire of Applicant or Agent 15ate /C/4,1c /'//S'� 11/17/95 5439 i FINANCE CODE CENSUS CODE Print Applicant's/Agent's Name C4 101