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Permit No. 4520 ` City of fino Hills PPLICATI•FOR BUILDING PERMIT AND Community Development I CERTIFICATE OF USE Si OCCUPANCY 2001 Grand Avenue Chino Hills,CA 91709 Building Address: Proposed Use - St No. 4977 Street FAIRWAY BLVD. GAS METER RESET APN 1028-174-01 THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT Lot 22 Block V Tract 2576 ❑ Struct. ®Plumb. Applicant REGANCY REALTORS 0 Mech. ❑Elect. C1 Grading St No. 12360 Street CENTRAL AVE Type of Project 0 New 0 Alter ❑Addition City CHINO Zip 91710 Phone 590-7114 ❑ Repair ❑ Convert. ❑ Demo ❑ Occupancy Permit Owner SUSAN V. KOSOFSKY Project Location on Size Description Property in Sq. Feet St No. 4977 Street FAIRWAY BLVD. I I City CHINO HILLS Zip 91709 Phone 714-859-440 1- Engr/Arch Lic No. 2 I I St No. Street 3. I I City Zip Phone 4. 4977 14977 14977 Contractor Lic No. REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION Sewer I Min. Depth I S/1/100 Size St No. Street City Zip Phone Cubic Yards Excavation Fill Over Excavation City Business License License No. Expiration Date 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 License Number Date Contractor Address City and Zip Phone Owner Builder Declaration I hereby irm 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 r'-7 I, as owner of the property, am exclusively contracting with licensed contractors to 4..J construct the project. ` , ❑ I am exempt under Sec_____, B&PC for this reason Date Initial Workers' Compensation Declaration I hereby confirm that I have a certificate of consent to self insure, or a Zoning Land Use certificate of Workers Compensation Insurance, or a certified copy thereof, CH/RS,IL1 Company POLICY NO. Setbacks I Model/Plan 0 Certified copy is hereby furnished Date Expires FY 15 I SY 5 RY 15 I SSY 15 El Certified copy is on file with the city City Verified______ Group/Division/Type Date Applicant Certificate of Exemption from Workers' Compensation Insurance VALUATION I certify that in the performance of the work for which this permit is issued, I shall not employ 500.00 any person in any man r, so as to become subject to the Workers Compensation,Laws of California. �(01/17 -' PERMIT FEES ./'‘, Date - ///?-1-—Applicant l O11�y ilat-4 `e,1-re��(_- NOTICE TO APPLICA T. If, after making this Certificate 0f Exemption, you should become subject Electrical Structural to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. I certify that I have read this application and state that the above Plumbing $4.5.00 Grading information is correct. I agree to comply with all City Ordinances and state laws and hereby authorize representatives of this City Mechanical Issuance $30.00 to enter upon the above mentioned property for inspection purposes. Geo Review Plan Check Issuance Ap ov d Total Permit Fee 1 k/✓f GZ-f.Ci Cif r1/?_,- /J//�� $75.00 / Signature 7( Applicant or Agepi Dat) ' I Date Issued Permit Number ! / 4/,4 4/49/ G-0 05/11/95 4520 Print Applicant's/Agent's Name FINANCE CODE GLi INSTRUCTION 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.). LENDER'S NAME LENDER'S ADDRESQ 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. • BUILDING INSPECTIONS RECORD • DATE INSPECTOR I DATE INSPECTOR Setback/Location I I Rough Plumbing Temporary Power Shower Pan Test Foundation Reinforcing Steel Stucco Mesh or Exterior Siding Excavation and Forms Insulation Slab Grade I Sewer Ground Plumbing Soil I I Interceptor Ground Plumbing Water I I Septic Tank Underslab Ducts I I Leach Line or Seep Pit Underslab Conduit Water Service Underslab Gas I - I Lath or Drywall Nailing Fireplace Foundation I Gas Line Air Test 5-/Z-'15 cf') Joists and Girders Final Energy Electrical Ground Final Plumbing Mid-Height Bond Beam Final Heating/A.C. 8-Foot Bond Beam Final Construction Final Bond Beam Final On Site Improvements Fireplace Bond Beam Final Off Site Improvements Roof Sheathing Final Dedication Framing and Ventilation Final Zoning Roof Covering Final Electrical Rough Heating Final Gas Service and Ground Developer Fees Paid Rough Electrical I Fire Dept. Approval Verified Bonding Certificate of Occupancy Over Head Electrical Fence Height Gates Heater I I Pool Drainage li I SEPTIC TANK GALS. SEEP. PIT X LEACH LINE WIDE LONG X DEPTH OF ROCK N. W. E. S. Inspector's Signature and Initials DATE OF ISSUANCE PERMIT NUMBER