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Permit No. 4430 0, • fl CITY OF CHINO HILLS APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE & OCCUPANCY COMMUNITY DEVELOPMENT 2001 Grand Avenue EMIRChino Hills, CA 91709 ADDRESS BUILDING , �K1�A.lAV \7`�.../O, PROPOSED USE 1 , CF .•'� /� k (g^_ten/_ Q, 'j/.'}, A O_ APN \^ P1� \'1Lt- l 1 I d�J THE FOLLOWING WORK IS AVOWED BY THIS PERMIT 0s 1/ LOT �� BLOCK TRACT 0 STRUCT 0 PLUMB ECH 0 ELECT 0 GRADING g ©ate�(� . t TYPE ERMIT 0 NEW 0 ALTER 0 ADDITION m C/7 APPLICANT \`kv 'D .� //F�W1��-�-3L EPAIR ❑ CONVERT 0 DEMO ❑ OCCUPANCY PMT Cde6 PROJECT LOCATION SIZE ADDRESS 1 1 A`` �(/Tli.�ku���/ ryLr���� -fp.� -��p DESCRIPTION ., I PROPERTY ON I IN SO FEET CITY�,)Ca%__ ZIP ` `K -gL7Y 117 1 Y)r\ l'cV r�'{ �1 I I OWNER S�K� 2 I I —S ADDRESS J I I 3 CITY ZIP PH I I 4 ARCHITECT e-/ ENGINEER LIC NO REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION ADDRESS NO STORIES NO DWELLING UNITS BEDROOMS CITY ZIP PH 41ROOF I FLOOR EXT WALL INT WALL CONTRACTOR LIC NO ADDRESS CEILING HEATING I METALMASONRY (its CITY 1i CITY ➢P PH SEWER MIN DEPTH S/F/100I SIZE (� CITY BUSINESS LICENSE (`v_ LICENSE NO EXPIRATION DATE LICENSED CONTRACTOR'S DECLARATION CUBIC YARDS EXCAVATION FILL OVER EXCAVATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of Division 3 of the Business and Prolusions Code,and my license is in full force and effect License Class License Number Date Contractor ADORroo CITY AND ZIP PHONE OWNER BUILDING DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason d._—es-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 O I as owner of the property am exclusively contracting with licensed contractors to construct the project ZONING I LAND USE (� 0 I am exempt under Sec B&PC for this reason \ ` I Date 'it-1--IA' INITIAL T ` ' SETBACKS I MODEVPLAN t v WORKERS COMPENSATION DECLARATION FY I SY I I hereby affirm that I have•certificate of consent to self insure ora certificate of Workers' Compensation Insurance or a certified copy thereof RY I SSV COMPANY POLICY NO GROUP DIVISION TYPE O Certified copy is hereby furnished DATE EXPIRES VALUATION a, 3 O Certified copy is filed with the city CITY VERIFIED �J Oat. APPLICANT PERMIT FEES CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE I certify that in performance of the work for which this permit is issued,I shall not employ any ELECTRICAL STRUCTURAL person In any mannersosogas to become subject to the kers Compensation Law of California C OaDate `—�` s`' APPLICANTC .. PLUMBING I GRADING NOTICE TO APPLICANT If,after making this Certificate of Le) PLUMBING you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply r///'''��, //77�) ^^^��� with such provisions or this permit shall be deemed revoked MECHANICAL Ie/• iX ISSUANCE FEES./ ,(l 1 (1 J I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMA TION IS CORRECT I AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS, GEO REVIEW I PLAN CHECK AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES ISSUANCE APPROVED I TOTAL FTF . Sign a of Applicant ant Date IA .— DATE OF I SUANCE PE MIT NUMBER �n� uNM�� L 7 �% IASO Print Applicant•/Agents Name j ' FINANCE CODE /� L Date: 4/27/95 00 Receipt II: 000000000 OCK 0 5 CHECK $53.28 WHITE- FILE/GREEN- FINANCE/ YELLOW- OFFICE/PINK-OWNER Amount Tendered $53.28 GOLD-ASSESSOR/MANILA - INSPECTOR •ONSTRUCTION LENDING AGENCS 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 ADDRF cc 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 APERSON 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 - I'' •• • _ ❑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 AND1THE WORK APPLIED FOR ON THIS PERMIT 'DIS DIS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY .� r.�„ • t ' r / J -, -,q.. ., y ."l..yf.+vl-..rw`v-,..,,1r ./71•,li'°„y-y- '--... cu-.- ^Mv.�.+'h.,,..nr.•..n..,.�.,. \\ • I CITY OF CHINO HILLS`' t;' g`iS"c 11/x'3. APPLICATION FOR A BUILDING PERMIT AND COMMUNITY DEVELOPMENT I ,.- r •„ A`CERTIFICATE OF USE &OCCUPANCY 2001 Grand Avenue _ t 11Chino Hills, CA 91709 5 BUILDING A h {Y.�yn,1n`�I0.\\\I PROPOSED USE 03C ADDRES\S 4 \ \� 111.1rVV'1`.l \J\ VOT------4-4 r APN \0 aid \-I '\_DAI `y I/ 1 �� s' Z THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT s LOT (3 -S1—•'+ BLOCK TRACT G7 .-s�l(r 0 STRUCT ❑ PLUMB ❑'MECH 0 ELECT 0 GRADING D OL O L TYPE OF PERMIT 0 NEW 0 ALTER 0 ADDITION IT (/)APPLICANT / GI".Y kik 4\ 't ''x”' ❑•REPAIR 0 CONVERT 0 DEMO 0 OCCUPANCY PMT ADDRESS „,„.,94.\ _AI '\\ \ 3 \. \1 l PROJECT I LOCATION ON I SIZE \ \ DESCRIPTION PROPERTY IN SO FEET CITY .k .,. -t v , L ZIP .� c1 ,y PHryry r41` ?'a1 rte I I fi 1 OWNERI I r ADDRESS I I r 3 `' CITY ZIP / PH I I ' I 4 ARCHITECT ENGINEER LIC NO REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION " C ADDRESS NO STORIES NO DWELLING UNITS BEDROOMS CITY ZIP PH _ CONTRACTOR LIC NO ROOF I FLOOR EXT WALL INT WALL ADDRESS CEILING HEATING I FIREPLACE 1 METAL MASONRY CITY ZIP PH SEWER MIN DEPTH 5/F/100I SIZE CITY BUSINESS LICENSE {� LICENSE NO EXPIRATION DATE LICENSED CONTRACTORS DECLARATION CUBIC YARDS EXCAVATION FILL OVER EXCAVATION I hereby ilium that I am licensed under provisions of Chapter9(commencing with Section 7000 of Division 3 of the Business and Professions Code, and my license is in lull force and enact License Class License Number Date Contractor ADDRESS CITY AND ZIP PHONE OWNER-BUILDING DECLARATION I hereby affirm that I am exempt from the Contractor's License Levi tear the following reason 0-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 oflered for sale O I as owner of the properly am exclusively contracting with licensed contractors to construct the protect ZONING I LAND USE O I am exempt under Sec B&PC tear this reason. I -- Date '•b 1 "t INITIAL�_ \� SETBACKS I MODEUPLAN WORKERS'COMPENSATION DECLARATION FY I SY 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 RY I SSV I COMPANY POLICY NO GROUP DIVISION TYPE O Certified copy is hereby furnished DATE EXPIRES O Certified copy is filed with the city CITY VERIFIED VALUATION -A \.A.) Dab APPLICANT PERMIT FEES CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE I certify that in performance of the work for which this permit is issued,I shall not employ any ELECTRICAL I STRUCTURAL person in any manner so as to become subject to the Workers Compensation Law of California , —1 Date ' I 1*--, APPLICANT PLUMBING I GRADING NOTICE TO APPLICANT If,after making this Certilmate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Coda you must forthwith comply r+ �j with such provisions or this permit shall be deemed revoked MECHANICAL 1 i x IISSUANCE FEES I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMA TION IS CORRECT I AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS, GEO REVIEW I PLAN CHECK AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES ISSUANCE APPROVED TOTAL PERMIT FEE {11J ;INI Signature of Applicant of Agent Date t 4 DATE OF ll SUANNCCjE q PE MI NU jER tity Print Applicant s/Agent•Name 1 O FINANCE CODE Li�• 1 WHITE- FILE/GREEN- FINANCE/ YELLOW- OFFICE/PINK- OWNER GOLD-ASSESSOR/MANILA - INSPECTOR Operator: VIR6INIR Check I: 000000000 Date: 3/14/95 00 Receipt It: 0000444 WHITE- FILE/GREEN- FINANCE/ YELLOW- OFFICE/PINK- OWNER CHECK $421.40 GOLD-ASSESSOR/MANILA - INSPECTOR , t RmDunt Tettered $421.40 ,ONSTRUCTION LENDING AGENCI 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) LENDERS NAMF LENDER'S ADDRGcc -QYI:ONSTRUCTION LENDING AGENC°S.A/ 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 ADDRFce 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 - O I CERTIFY THAT NO EXCAVATION 5 FEET OR MORE FEET IN DEPTH,INTO WHICH APERSON 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 - • O 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 OIS OIS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY - \• 4 ,,• •r • • - •, . r. 3. .