Permit No. 3863 =;to CITY OF CHINO HILLS APPLICATION FOR A BUILDING PERMIT AND
A CERTIFICATE OF USE &OCCUPANCY
COMMUNITY DEVELOPMENT
•.;.• • 2001 Grand Avenue
®l Chino Hills, CA 91709
BUILDING q LL y. .Iy-�,A 1 PROPOSED USE0 CO
ADDRESS 13 Ll I 1-koa-cf 5 'Nvei La tJ e� FA-(0,,��c.JJQ�I ..S ".1/4".
�I4� C
r
7
APN THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT L3
�/ D
LOT Iry / BLOCK TRACT / 0 STRUCT 0 PLUMB ❑ MECH ❑ ELECT ❑ GRADING 0
`�`/ I O
9
1 / , TYPE OF PERMIT 0 NEW 0 ALTER 0 ADDITION N
APPLICANT Y A-rl yl V Ni £ r 5A-
III��\.. !� �{ I r' /�.�A/p 0 REPAIR 0 CONVERT' 0 DEMO 0 OCCUPANCY PMT y
SIZE
ADDRESS ♦3�T� +I IS
A- 65ISy-R�y NPS (�(7 1v lj
DESCRIPTION /� I
PROPERTY I INNV SO
FEETs
CITY C Ft-llr/1./ I+ills ZIP q r 7/ b'9 PH 3-51-73671 �1e•✓R I I J /`--�
OWNER Si!. ,nviilt p/ 2 I I
ADDRESS lI I W
3 ()
CITY ZIP PH I I
4
ARCHITECT
ENGINEER vkI -<jlc-bh/fl LaildSC�¢IitiNo 7REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION
ADDRESS �j -1OrT,Vl NO STORIES NO DWELLING UNITS BEDROOMS
CITY ZIP PHS [q ISO ROOF I FLOOR EXT WALL INT WALL
CONTRACTOR LIC NO
ADDRESS CEILING I HEATING I FIREPLACE
METAL MASONRY ����(((((����
CITY ZIP PH SEWER I MIN DEPTH I S/F/100I SIZE
CITY BUSINESS LICENSE
LICENSE NO EXPIRATION DATF
LICENSED CONTRACTORS DECLARATION CUBIC YARDS EXCAVATION FILL OVER EXCAVATION
I hereby allirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 /C'1
of Division 3 of the Business and Professions Code and my license is in full force and effect f
License Class License Number lac. X. I �/^
/- +OO W
Date Contractor 1
ADDRESS C
CITY AND DP PHONF
OWNER BUILDING DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason
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 offered for sale
O I as owner of the property am exclusively contracting with licensed contractors to construct
the protect II-`, r' 1Z/OYNING I LAND USE
O I am exempt under See B&PC for this reason -' C
I I /PO
P11 1 7 ISI I
/ — Date �O/KERS/COMPENSATION DECLARATION INITIAL
� FY IS E1TA�,A/1CCKSS SY I MODEL/PLAN
I
1 hereby affirm that I have a certificate of consent to self insure,or a certificate of Workers' I^�
Compensation Insurance,or a certified copy thereof RY A I / I SSY 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 go"
Date APPLICANT
PERMIT FEES
CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE
certify that in a ner so
o as of become mework tor ct whichthe is permit is issued,I shall not employ an ELECTRICAL da�-rl I STRUCTURAL �fl L O
I
person in any rtpeforsanc tob h• k for subject the Workers'rmit' omuen all Cal nes �/ ``LJ l�J
�I7t� Date /17��( 7y APPLICANT V PLUMBING /�,� I GRADING J
I NOTICE TO APPLICANT II,after making this Certificate of Exemption you should become VJ
subject to the Workers Compensation provisions of the Labor Code,you must forthwith comply ^ /
with such provisions or this permit shall be deemed revoked MECHANICAL ISSUANCE FEES a
I CERTIFY THAT 1 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
Q
/ - q ISSUANCE APPO I TOTAL PERMIZFEE
• .�2ll (7, Y'��JGE-.Kip ////9`1! �/ , (SUr(8
Sign lure of Appli4ant or Agent v(�' Date /
/V`-Me/Z yA/ y r c i4 R yr DATE\OF{Si UA E I PERMIT NUMBER
Pnnt Applicants/Agents
TION ` I I6(L\ 3 6S
FINANCE CODE C--14
i.tOr: IAN [neck t,: 000001232
WHITE- FILE/GREEN- FINANCE/ YELLOW- OFFICE/PINK-OWNER :'-•e% 11/17194 CO REcefDt 8: 0000813
;.Neck 888.CKt
GOLD-ASSESSOR/MANILA - INSPECTOR
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM THAT THERE ISA CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
(SEC 3097, CIV C)
LENDER'S NAM' LENDER'S ADDREcc
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
THE CALIFORNIA HEALTH AND SAFETY CODE REQUIRESA DIVISION OF INDUSTRIAL SAFETY PERMIT AS A PREREQUISITE TO PERMIT ISSUANCE UNLESS
THE APPLICANT SIGNS ONE OF THE CERTIFICATES BELOW
D 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 DIS DIS NOT SUBJECT TO THE
APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY
To
-it>,
CITY OF CHINO II
, ALICATION FOR A BUILDING PERMIT AND
.rt.... COMMUNITY DEVELOPMENT A CERTIFICATE OF USE & OCCUPANCY
• - 2001 Grand Avenue
tit'`ligaigiiiiiiiii Chino Hills, CA 91709
co
ADDRESS I mot lY I , 1 sit N, t v PROPOSED US . ci /`^ , l i / O
APN oz,C'. I 'ill THE FOLLOWING WORK IS AUTHORIZED BY THIS PERT
D
LOT BLOCK TRACT/2461 0 STRUCT 0 PLUMB 0O
tt /
,e TYPE OF PERMIT 0 NEW 0 ALTER 0 ADDITION CD
T
APPLICANT , I .1- • ,y Co
0 REPAIR 0 CONVERT 0 DEMO 0 OCCUPANCY PMT
ADDRESS ' t I t I r ".'l.,r PROJECT I LOCATION ON I SIZE
DESCRIPTION PROPERTY IN 80 FEET
CITY • ZIP t ( PH / 1 Cr.A7d0, I I'�t�-•(y
OWNER 1i 1 ,/ 2 I I I`
ADDRESS
3
i
CITY ZIP PH
4
-- ENGINEERT ! t
0 LIC NO REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION
ADDRESS NO STORIES NO DWELLING UNITS BEDROOMS
CITY ZIP PH r . '
ROOF I FLOOR EXT WALL INT WALL
CONTRACTOR - - LIC NO
4.
ADDRESS CEILING HEATING I
METALMASONRY
CITY ZIP PH SEWER MIN DEPTH S/F/100 I SIZE
CITY
BUSINESS LICENSE
LICENSE NO EXPIRATION DATF
LICENSED CONTRACTOR'S DECLARATION CUBIC YARDS EXCAVATION FILL OVER EXCAVATION
I hereby affirm that I em licensed under 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 ` 1[ //-.
License Class License Number 1 4 l $ I I[ /- - ' /.-_r+ '
Date Contractor
AODRESC
CITY AND ZIP PHONE -J
OWNER BUILDING DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason
O 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 offered for sale
O I as owner of the property,am exclusively contracting with licensed contractors to construct ZONING I LAND USE
the protect
O f 1 am exempt under Sec B&PC for this reason � T i: . _, L..-1
r I
.�, Det• o. i INITIAL - SETBACKS I MODEL/PLAN
WORKERS COMPENSATION DECLARATION FY 1I SY I
I hereby affirm that I have a certificate of consent to self insure,or a certificate of Workers'
Compensation Insurance,ore certified copy thereof RY t ) I SSY 1-5 I
COMPANY POLICY NO GROUP DIVISION TYPE
O Certified copy is hereby furnished DATE EXPIRES
VALUATION 1 i^
O Certified copy is filed with the city CITY VERIFIED
Det• 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 —NI' •C I) I STRUCTURAL-Th d " � 0
as in any manner so to become subject to the Workers Compensation Law of CAbfornie
y .
�. Date / APPLICANT 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 i
with such provisions or this permit shall be deemed revoked MECHANICAL ISSUANCE FEES 1
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 PLAN CHECK
AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE
MENTIONED PROPERTY FOR INSPECTION PURPOSES
ISSUANCE APPROVED TOTAL PERMIT FEE
Signature of Applicant or Agent Date
DATE OFI S 1
I PET M�R
y / • s '
Print Applicant s/Agents Name
FINANCE CODE
WHITE- FILE/GREEN- FINANCE/YELLOW- OFFICE/PINK- OWNER
GOLD-ASSESSOR/MANILA :INSPECTOR
ONSTRUCTIDN LENDING AGENC
I HEREBY AFFIRM THAT THERE IS A CONSTRUCON LENDING AGENCY FOR THE PERFORMANCE allIFHE WORK FOR WHICH THIS PERMIT IS ISSUED
ilikit
(SEC 3097 CIV C)
LENDER'S NAME LENDER S ADORE cc
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
THE CALIFORNIA HEALTH AND SAFETY CODE REQUIRESA 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 3e 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 OS CBS NOT SUBJECT TO THE
APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY
BUILDING INSPECTIONS RECORD
DATE INSPECTOR DATE INSPECTOR
Setback/Location Rough Plumbing
Temporary Power Shower Pan Test
Foundation Reinforcing Steel Stucco Mesh or Exterior Siding
Excavation and Forms Insulation
Slab Grade Sewer
Ground Plumbing Soil Interceptor
Ground Plumbing Water Septic Tank
Underslab Ducts Leach Line or Seep Pit
Underslab Conduit Water Service
Underslab Gas Lath or Drywall Nailing
Fireplace Foundation Gas Line Air Test
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 Fire Dept Approval Verified
Bonding Certificate of Occupancy
Over Head Electrical
Fence Height
Gates
Heater
Pool Drainage
i i
/1/771W CN a ler,../ T.r f big
v/ / /
4- erS a /L //Z.PO/9 41 Cil e°
/ ii -
i7) i '7 /crC- f—(iv
-- -i 4-1/ • // —
SEPTIC TANK GALS v
SEEP PIT X
LEACH LINE WIDF
LONG X DEPTH OF ROCK
N
W E
S Inspector's Signature and Initials
DATE OF ISSUANCE PERMIT NUMBER