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Permit No. (20) 411) 106 SAN BERNARDINO COUNTY-EPWA/LAND 1 AGEMENT DEPT , OFFICE OF,BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR 106 91 01179 205A 01 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL DATE 09/18/91 I ISSUE DATE 09/18/91 I PG 1 OF 1 PARCEL NUMBER 1028-174-18-0000 / PROPOSED USE: CARPORT/RM.ADDN./GAR.CONV. z y - CURRENT USE: RESIDENCE BLK LOT SEC IVITY : 825 2576CT 1 000 1 001 1 NE27 1 08W I 02SCL 00AP I PRCL COMMUNITY TY PLANL823 LONE/LAND USE DISTRICT GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS CH/RS,IL1,L-M LOT DIMENSION IRREGULAR CONST TYPE VN APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER *BLDG'S ON LOT 1 (GROUP R3 HAM, FRANK 4961 FAIRWAY BLVD #PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 49-155 CHINO HILLS CA 91709-0000 STD PLAN/ICBO FHA N (714) 597 - 2089 TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER HAM, FRANK 1 240 .50 120.00 4961 FAIRWAY BLVD 2 136 .50 68.00 CHINO HILLS CA 91709-0000 CARP 400 .20 80.00 (714) 597 - 2089 CALC. VALU 12,973.88 I ADJUSTED AREA 268 JOB SITE ADDRESS ' 4961 FAIRWAY BLVD ITEM CNT DESCRIPTION DETAIL TOTALS CHIN HILLS CA 91709-0000 RESIDENTIAL CONSTRU 167.00 CROSS STREET AVERY STREET TOTAL AMOUNT 167.00 INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER DIV. OF IND. SAFETY PERMIT: MINIMUM SETBACK DISTANCES 50 FRPTf SETBACK/CENTRLINE FAIRWAY BLVD R/W 50 15 REAR SETBACK/PROP LINE / 50 SIDE SETBACK/CENTRLINE QUAIL R/W 50 / 5 SIDE SETBACK/PROP LINE Zr MECHANICAL EQUIP NOT PERMITTED IN REQUIRED SIDE SETBACKS NO. STORIES ( NO.UNITS1 WNL DWELLING NO. BEDROOMS FLOOR EXT. WALLS I INT. WALLS CEILING %.9 STUCCO SHEETROCK SHEETROCK `.LP' ' 47 ROOF HEATING FIREPLACES Q\ ~" < COMP SHINGLE NATURAL GAS METAL IMASRY c p PUWATER BLIC 1 SEWER 1 MIN DOEPTHI S.00O10010000E1 NEW/REPAIR00 °���� COMMENTS <5i'- 09/18/91 PERMIT TO INCLUDE 400 S.F. CARPORT, 240 S.F. GARAGE CONVERSION TO BEDROOM, 136 S.F. LAUNDRY RM. ADDITION. PRE ALTER DONE BY BRUCE HEWARD. O.K. TO ISSUE PERMIT PER DEBBIE KIRAC, C.V. MANAGERS. D.FLETES. AMT WAIVED .00 AMT PAID 167.00 PAYOR NAME: B AND B REMODELING PAID 09/18/91 RECEIPT 3815 EMPL: FLET:,, DEBORAH PAID DY : CHECK NBR : 2483 a • ICENSED CONTRACTORS DECLARATION - I HEREBY AFFIRM THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SE ON 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 STRUCTURE,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)OF 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 ENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($5001.): 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 R OFFERED FOR SALE(SECTION 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY HO 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 CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW). ❑ I AM EXEMPT U ER SEC. �/ B. AND P. C. FOR THIS REASON Q� QNER `-42IA H `4477 DATF / "/? — ? / // V 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 DATE ADDITIONAL REVISION 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 I. 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 HAVE READ THE HAZARDOUS MATERIALS QUESTIONNAIRE AND THE WORK APPLIED FOR ON THIS PERMIT ❑ IS ❑ IS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY. 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` � PURPPOO ES. ��y/ /y D IG ATURE OF APPLICANT OR AGENT %//L---P�1 /i. / / 1 )7r, /G' DATE `'( "�/O - q/ V 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.4190 '-N`-Owner Name 144V__ Permit Numb jj`U ?/C)/(7 `, INSPECTION RECORD DATE I INSPECTOR I / I DATE INSPECTOR Setback (?-1S_'7Z. Rough Plumbing / Temporary Power StroWie .an Test Foundation Reinforcing Steel St14cco Mesh or Extericif Siding Excavation and Forms > ,./' 00 0 /L' Insylation F.H. ndati / h''„ ' DnI Sew' r Slab Grade i, / Interceptor Grounp Plumbing' Septic`jank Underslab Ducts Leach Lke orAeep Pit Underslab CoAduit Water Se\vije Fireplace'k91ndation Lath or Drywall Nailing Joists and/girders Gas Line/Aie Test ElectricaVVGrpund Final EVergy\ Mid-Heijiht Eiond Beam Final Vlumbinai , ,V 8-FootLBond Beam Final`Heating/A.C. „ 1/ Final Bond-Belem Final Construction t rit O // Fireplace Bonc1Beam _ Final On Site Iillprovements ‘ e \Ur /n Roof Sheathing ` , ,i (\IA Final`%ff Site/Improvements ( U (--) \ / \\ Framing and Ventilation / f�/i \UV U vxY 1 Final D icqkion It 1 \./,\ Roof Covering I` - �' '' IVFinal Zon14 ` I\ I \\ (A\ Rough\qeating, Final Elecy4i)vl I / \.1/ Electrical`ke4Gice and Ground Final Gag' \ I / A Rough Eleical Develoq/er Fees' aid I ( V WC (YIN) .. Ind Saf (Y/N) Certifittate-of-Oecupancy 72y�/L—c'-7 6' �r1 • SEPTIC TANK GALS ^MT AA4Iv 1 SEEP. PIT X �- �.�' LEACH LINE WIDE �w^P--S16 � v ) X LONG X DEPTH OF ROCK a'fF N. 1 .rp• W. E. S. Inspector's Signature and Initials n41. >dlh -PX0— r`-W\ 12.17589-469 Rev.3188 dV U