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Permit No. 2941 CITY OF CHINO HILLS 1 0 COMMUNITY DEVELOPMENT 2001 Grand Avenue APPLICATION FOP A BUILDING PERMIT AND A CERTIFICATE OF USE &OCCUPANCY Chino Hills, CA 91709 IC\ IN BUILDING CLE E`D B� APPLICATION PE / NO CO ADDRESS I���f t�r IClG1P, V1• �f ��� �/ F J g APN D 0 0 _ 5 — lJ/1 Z g THE FOLLOWING WORK IS AUTHORIZED BYT HERMIT LOT ) BLOCK TRACT I�jq• is-9. ❑ STRUCT ❑ PLUMB ❑ MECH C (ECT 0 p(`/� 11 r JO TYPE OF PROJECT ❑ NEW ❑ ALTER ❑ ADDITION M OWNER U C pea's ❑ REPAIR ❑ CONVERT ❑ DEMO ❑ OCCUPANCY PMT I P ROJECT I LOCATION ON I SIZE ADDRESS y I Q w ' • L 1 N Co I K- S�re 200 DESCRIPTION PROPERTY IN SO FEET CITY cz r cm a i ZIP q t r7 an PPFFf6C1) g 407 I I t ARCHITECT I ENGINEER LIC NO 2 ADDRESS 3 I I CITY ZIP PH REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION CONTRACTOR I-:, ) V rQ Y\, U4-1 1 4-11/ N j c ek, 1 irz I Y ���v IC s ► �•e► mporakcvi TnLA Poles It ADDRESS a7ao ea S RQ real ?o`r k 1r • 1 1 CITY ArnQJ) La!hei rn ZIP 9a 2bCo P" O03o • LICENSE NO I W el EXPIRATION DATF CITY BUSINESSLICENSE 30_9 Q \\ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of Division 3 of the Business and Rrofessions Code,and my license is in full force and effect License Class- C —10 C-LI License Number 5 a 3 S q LP) �^_� R Date -7` a 1 —61 q Contractonr 1 QV aero rr\r LI�1' I 1 4 Sew 1 \ ADDRESS -� -n EAST Cl QC�A,1 I 1--)0,1r 'If' CITY AND ZIP ht h r h1 1 1M PHON(� /44) OWNER-BUILDING DECLARATION kN I hereby affirm that I am exempt from the Contractor's License Law for the following reason ❑ 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 ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the protect ❑ I am exempt under Sec BBPC for this reason Date INITIAL • WORKE RS'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 ��,�ft �} C,c r/ COMPANY SA-0.--Ve �ur'd POLICYNO3(J1 o —q3—c:7,56(1 634.4 • GROUP DIVISION TYPE ❑ Certified copy is hereby furnished DATE EXPIRES 1 1, ' I Certified copy is filed with the city CITY VERIFIED �VALUATION Date 5'x-7_ r APPLICAyfi �'i✓h��-� �/�JL:L.,1C e/ PERMIT FEES CERTIFICATE OF EXEMPTION FROM WORRRS'COMPENSATION INSURANCE I certify that in the performance of the work for which this perrtxt is issued.I shall not employ any person in ELECTRICAL ' g" Workers' I STRUCTURAL any manner so as to become subject to the Compensation Laws of California 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 with such provisions or fes this permit shall be deemed revoked MECHANICAL I ISSUANCE FEES,,,iii 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 I PLAN CHECK AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSE ISSUANCE APPROVED TOTAL PERM E (The'(2 52,77/9'71i7/ D I Sgnatu 8f Applicant or Agent 0 Date \lP.VI✓I�I j T f I-e�J DATE OF IS ANCE PERMIT NUMBER /// liPrint Applicant's/Agent's1Name Ime I Il /7��' I V' 67�/ / l�� rif dir '33 S Operator: VIRGINIA Check 4: (1000020(9 Date: 5/27/94 00 Receipt 44: 0001045 CHECK WHITE-INSPECTOR/GREEN-FILE/YELLOW-FILE/PINK-OWNER/GOLD-ASSESSOR • • BUILDING • ADDRESS • LOT BLOCK TRACT BUILDING INSPECTIONS RECORD OWNER ADDRESS CITY ZIP PH PLUMBING DATE APPROVED/INSPR'S SIGNATURE • GROUND SOIL/WATER P1 TOP OUT P2 SHOWER PAN P3 REMARKS SEWER P5 GAS TEST P6 FINAL PLUMBING P12 p /` • MECHANICAL DATE APPROVED/INSPR'S ��/-!4/ cf� SIGNATURE UNDERGROUND FLOOR M1 ROUGH M2 FAU/AC Ma • FINAL MECHANICAL M12 ELECTRICAL DATE APPROVED/INSPR'S SIGNATURE TEMP.CONSTN.POWER E3 ?/,J`/fc� UNDERGROUND PVC-METAL-D B.0 El ROUGH WIRING RECEPT SPACING- SERVICE-CIRCUIT E2 L . FINAL ELECTRICAL E12 7/�7 STRUCTURAL / DATE/ ~APPROVED/INSPR'S SIGNATURE FOUNDATION LOCATION S1 REINFORCED 0 UFER 0 SLAB REINFORCED 12 MEMBRANE S3 FLOOR FRAME/INSUL. S4 MASONRY S11 FIREPLACE Si ROOF FRAMING ROOF SHEATHING S5 FRAMING S6 INSULATION SOUND ENERGY S7 LATH EXTERIOR S8 LATH INTERIOR/GYPBOARD S9 APPROVED/INSPR'S SIGNATURE DATE OF ISSUANCE PERMIT NUMBER BUILDING FINAL S12