Permit No. 1055 CITY OF CHINO HILLS
COMMUNITY DEVELOPMENT /IIIP
2001 Grand Avenue APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE &OCCUPANCY
Chino Hills, CA 91709
BUILDING i ,) _I 4€ I��� /
CLEAREDBY APPLICATION NO O
ADDRESS IOJy�'/�lW/� %F//�(/l� / l/ C
APN / Oh/fig 9�I�. iL THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT D
LOT —I )p -6 BLOCK�1 TRACT6�CY /I RUCT LUMB �'A�ECH ELECT 0
33
!� / TYPE OF PROJECTW D ALTER ❑ ADDITION m
OWNER �:/► / CO
�• O /�_...6r.. .,.,500� ❑ REPAIR ❑ CONVERT ❑ DEMO ❑ OCCUPANCY PMT �
ADDRESS �/� f—/�� \ PROJECT LOCATION ON SIZE
v (/� �/ (/I/L� DESCRIPTION PROPERTY INSO FEET
CITY(/ Wf / 1 Zl /T /\ PH 1 1M:04/ di I 7 I /��! 1.
ENG ARCHI g,g;
NI ERT LIC NO24,,,,,. ..zi7a... �.
ADDRESS 3724.1-g
/"/�9 6 I/ I /�/ V
CITY ZIP PH, REMARRKKS//SPECIAL CONDITIONS/PROJECT DESCRIPTION I t
CONTRACTO5 .�/D LIC NO
ADDRESS
CITY ZIP PH
•
CITY BUSINESS __
LICENSE NO 1(C► EXPIRATION DATE LICENSE �_/__;.„3/ 6/-3. //� '
LICENSED CONTRACTOR'S DECLARATION L / /�`/,J"/�+/j"/v�,///y/9 !�
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of N.
Division 3 of the Business and Professions Code,and my license is in full��force(and effect g I
License Class c6 License Number `—ter r ' ,6 /,� ,k
ji.
Date /� �,{ CContrra�ctor +""�7/�,r��^�"/^" ��r\}T' n !riW
ADDRESS /t 71 "�}`(��/(Lc/)`l(�� - I ( 1 I�y/' .. J 1/b, . \l I'1 1
CITY AND ZIP Lor o 69�—""6 ' PHONE t gib r� — w I N k\(V r
OWNER-BUILDING DECLARATION I
\ v`l
I hereby affirm that I am exempt from the Contractor's License Law for the following reason tf� `
❑ I,as owner of the property,or my employees with wages as their sole compensation,will do the work, t/1`
and the structure is not intended or offered for sale 1\
❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project 1
❑ I am exempt under Sec B&PC for this reason
Date INITIAL
WORKERS'COMPENSATION DECLARATION ad-ii'v— " �y /775'7 7�
I hereby affirm that I have a certificate of consent to self insure,or a certificate of Workers'Compensation
c.w
Insurance,or a
certified copy
thereof
(/��
COMPANY I Y NO kr ��Li(76:21-.1
�'�'�_ / GROUPiteDIVISION TYPE //�
❑Certified copy is hereby furnished DATE EXPIRES 4 ���/// v ,v
(t 7;ertified copy is filed with the city CITY VERIF�IEn r VALUATION 4',/ ���Ji f a? /��
Date APPLICANT /1 1 /�/3 PERMIT FEES (,
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
I certify that in the performance of the work for which this permit is issued,I shall not employ any person in ELECTRICAL' STRUCTURAL
any manner so as to become subject to the Workers'Compensation Laws of California
Date APPLICANT / / I V
PLUMBING I GRADING
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
the permit shall be deemed revoked MECHANICAL , ISSUANCE FEES
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS
CORRECT I AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS,AND HEREBY GEO REVIEW PLAN CHECK.
AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED 1 _
PROPER OR INSP C + "oSES ISSU PROVED TOTAL PERMIT I'et
SignatJre of Apel t ga{ 0-6—F5
`}�/-�- \ Date/ /
or-- - ,t" .."40111r A‘Z4 3 -.3A.3 /i ! / J
Mall �V1 I(. DATE OF ISSUANCE PERMIT NUUMBER
PrintApplicant's/Agent's Name t � �o I ! 65
•
Operator: DAWN Check #: 000000000
Date: 3/23/93 00 Receipt #: 0000704
WHITE-INSPECTOR/GREEN-FILE/YELLOW-FILE/PINK-OWNER/GOLD-ASSESSOR CHECK $1113.00
I 1dr 4111/
k
BUILDING
ADDRESS
LOT BLOCK 'TRACT
BUILDING INSPECTIONS RECORD
OWNER
ADDRESS
CITY ZIP PH
a 10'T 3 �RERS
GROUND SI L 4194 ' P1 Iffy I /ii' 7/
TOP OUT - w P2 I 0,1 -
SHOWER PAN P3 REMARKS
SEWER P5 L1 ).2• CP) I -1-vl i 4104 4 ,. J AW"
GAS TEST P6 6/2•1 ' I Q.VJA a
FINAL PLUMBING P12 /64 .�� /
MECHANICAL ' / DA E .1' APPROVED/INSPR'S
SIGNATURE
UNDERGROUND FLOOR Ml I I
ROUGH M2 I ('•/. I V
-09-
FAU/AC M4 I ' I
1I ,
FINAL MECHANICAL M12 I/ I ,r"."7,04°.°-
ELECTRICAL DATE APPROVED/INSPRS
SIGNATURE
TEMP CONSTN POWER E3 I
UNDERGROUND
PVC-METAL-D B.C. El
ROUGH WIRING (2.,RECEPT.SPACING- G It.
SERVICE-CIRCUIT E2
1" _
FINAL ELECTRICAL E12 /64,y/s, I+7,
STRUCTURAL ' SATE 71 AP/PROVED/INSPR'S
, SIGNATURE
FOUNDATION LO,fd., U •S1 , 41 '`Z 4I^
REINFORCED Cr,��' UFER v
SLAB REINFORCEDPMEMBRANE 3 (4 Ifs: l0l
FLOOR FRAME/INSUL. S4 1 I 11YY
MASONRY ' S11
/
FIREPLACE S11 I Ali 0 ! , ,fieri /l X/ 1___5
ROOF FRAMING /�
/ i
ROOF SHEATHING--.N.... S5 //� o���vlK�it/ 1 > T7 N7 �/
FRAMING- S6 I -4/ZJ I
•
SOUND EONERGY N S7 I foh C/
LATH EXTERIOR S8 ( i
LATH INTERIOR/GYPBOARD S9 I I
. //J7 /``4 / /7
• . 4 � �w
APPROVED/INSPR'S / L 4--e, //�/0Y l
/ SIGNATURE 'DATE OF ISSUANCE PERM?NUMBER
BUILDING FINAL S12 /44y/f3 ••
/06/r."
r .
/ '
al
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