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Permit No. 19866 BUILDING ADDRESS: 1 5040 JADE TERRACE I PLAN CHECK NUMBER: 19866 I BUILDING INFORMATION APPLICANT INFORMATION �� t�ho�1 BUILDING PLAN CHECK Address: 5040 JADE TERRACE Name 'ELIZABETH KRUSE IP:4- Community Development APN. 11017-503-30 ' Address 114730 CENTRAL AVENUE "'#y ' 2001 Grand Avenue Lott 130 City,Zip Code. 'CHINO,CA 91710 Chino Hills,CA 91709 ��4,�;,y+.�• Chi Cross Streets: 1GRAYSTONE Phone/Pager 1(909)614-1333 ' ext. ' IF,IIIl'llnr,Tll. LICENSED CONTRACTOR DECLARATION Tract/Parcel: 114285 City Bus Lic#: I hereby affirm that I'm licensed under the provisions of Chapter 9(commencing with Section Valuation: 1$3,000.00 ENGINEER/ARCHITECT INFORMATION 7000 of Division 3 of the Business and Professions Code)and my license is in full force and effect OWNER INFORMATION Name. !POOL ENGINEERING OWNER BUILDER DECLARATION Name 'ALEX HART Address. 11201 N.TUSTIN AVENUE I hereby affirm that I'm exempt from the Contractor's License law for the following reason. Address: 15040 JADE TERRACE ( City,Zip Code.(ANAHEIM,CA 92807 I,as the owner of the property,or my employees with wages as their whole City,Zip Code (CHINO HILLS,CA 91709 Phone I 1 ext. I 0 compensation,will do the work,and the structure is not intended or offered for sale. Phone: 1(909)606-3520 I ext I Lie# I,as owner of the property,am exclusively contracting with licensed contractors to Bus Lie 4: City Bus Lie#. construct the project. p: APPROVAL INFORMATION 0111 Bus Ex 1 am exempt under Section I BPC for this reason ' CONTRACTOR INFORMATION Issued By. IYVETfE MARTINEZ WORKERS'COMPENSATION DECLARATION Issued 4i 16/02 I hereby affirm under penalty of perjury one of the following declarations: Contractor 'SPLASH POOLS Address: 114730 CENTRAL AVENUE I Finance Code: 1C7 I have and will maintain a certificate of consent to self-insure for workers'compensation Census Code. ' 0 as provided by Section 3700 of the Labor Code,for the performance of the work for City,`Lip Code: CHiNO,CA 91710 Final Date. which this permit is issued. Phone or Pager: (909)614-1333 I ext 1 Bus.Lic.#• 102-05745 I Final By I have and will maintain workers'compensation,as required by Section 3700 of the Lic 4 1784292 Extension: G) Labor Code,for the performance of the work for which this permit is issued My workers'compensation insurance earner and policy number are: Exp Date: 19/30/02 Reviewed By: Lie Class• 1053 Approved By: INSURANCE INFORMATION1 PROJECT INFORMATION Insurance Company: STATE FUND I 1 Policy Number '1613386-00 PROJECT DESCRIPTION LOCATION SQUARE FT. Expiration Date. 9/30/02 Structure: I i U Section need not be completed if permit is for one hundred dollars($100)or less Garage ( I 1 Patio. I 1 1 certify that in the performance of the work for which this permit is issued I shall not employ .ny person in any manner so as to become subject to the Workers'Compensation laws of Porch: California and agree that if I should become subject to the workers'compensation provisions of Other SPA I REAR I ' Section 3700 of the labor Code. I shall comply with those provisions. PROPOSED USE SPA Date: i i Signature: i I I certify I have read this application and state that the above information is correct I agree to COMMENTS comply with all City Ordinances and state laws and hereby authonze representatives of this City to enter upon the above mentioned property for inspection purposes n( J l^ Date: - U(J. Signature: i r v A�-•l`7 r/ Y 1i (P OTHER FEES RE ZONING SETBACKS l GRADING QUIRED PRIOR TO PLAN CHECK FEE INFORMATION ACTUAL PERMIT Zoning. 1PD Front Yard 1 18 1 Over X: 1 0 I initial Plan Check: I $42 12 1 Land Use, FR-I Side Yard 1 5/5I Cut. j NO Cut• 0I Initial Structural ' $0.00 Total Fee Due X42.12 I'i. SPA Rear Yard ' 20 Fill 0 Development ' NO Initial Geo Review $0.00 cci It3 SSY Sewer' NO )I 1 I I Total: I 0 I Water. NO Initial Grading $0.00 i Type VN I —._