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Permit No. 19867 BUILDING ADDRESS: 5040 JADE TERRACE PLAN CHECK NUMBER: 19867 �� BUILDING INFORMATION APPLICANT INFORMATION , .t BUILDING PLAN CHECK Address: 15040 JADE TERRACE Name: !ELIZABETH KRUSE s , Community Development APN. 11017-503-30 Address 114730 CENTRAL AVENUE ';" 4 ' 2001 Grand Avenue Lot: 130 1 City,Zip Code: 1CHINO,CA 91710 4.-t4, Chino Hills,CA 91709 Cross Streets. IGRAYSTONE Phone/Pager 1(909)614-1333 I ext. 1 .9.°11211"°V LICENSED CONTRACTOR DECLARATION Tract/Parcel. 114285 City Bus Lic#: 1 I hereby affirm that I'm licensed under the provisions of Chapter 9(commencing with Section Valuation. 1$2,760 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 DECLARATIONName: 1ALEX 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 I City,Zip Code,1ANAHEIM,CA 92807 i,as the owner of the property,or my employees with wages as their whole City,Zip Code 1CHiN0 HILLS,CA 91709 I Phone. 1 1 ext. 1 compensation,will do the work,and the structure is not intended or offered for sale. Phone: 1(909)606-3520 1 ext. 1 Lie#. 1 I,as owner of the property,am exclusively contracting with licensed contractors to I 1 City Bus Lie#- 1 construct the project. Bus i am exempt under Section i I BPC for this reason Bus Lie# I Exp: 1 APPROVAL INFORMATION CONTRACTOR INFORMATION Issued By YVETTE MARTINEZ WORKERS'COMPENSATION DECLARATION Contractor SPLASH POOLS I Date issued 4/16/02 I hereby affirm under penalty of perjury one of the following declarations: Address 14730 CENTRAL AVENUE 1 Finance Code: 1C7 I have and will maintain a certificate of consent to self-insure for workers'compensation Code: as provided by Section 3700 of the Labor Code,for the performance of the work for City,Zip Code: CHINO,CA 91710 which this permit is issued. Phone or Pager 1(909)614-1333 1 ext. 1 Final Date. Bus.Lic.# 102-05745 Final By. i have and will maintain workers'compensation,as required by Section 3700 of the Extension Labor Code,for the performance of the work for which this permit is issued My Lic.4: 7R4292 workers'compensation insurance carrier and policy number are: Exp Date 19/30/02 Reviewed By, Lic Class• 1053 ( Approved By INSURANCE INFORMATION PROJECT INFORMATION Insurance Company- 'STATE FUND 1 Policy Number. 11613386-00 1 PROJECT DESCRIPTION LOCATION SQUARE FT. Expiration Date: 19/30/02 Structure. e Section need not be completed if permit is for one hundred dollars($100)or less Garage• 1 1 I 1 Patio LATTICE REAR 230 I certify that in the performance of the work for which this permit is issued. !shall not employ 1 ( 1 1 ivpersonin 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. I I I I Section 3700 of the Labor Code. I shall comply with those provisions. PROPOSED USE (LATTICE PATiO COVER WITH GAS AND ELECTRICAL STUB FOR FUTURE BBQ 1 . Date: i I Signature: I l I certify i have read this application and stale 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 Date: W 0, Signature: I I� ,( OTHER FEES ZONING SETBACKS GRADING REQUIRED PRIOR TO PLAN CHECK FEE INFORMATION ACTUAL PERMIT Zoning. 1PD I Front Yard. 1 18 1 Over X• 1 0 1 School' ' NO initial Plan Check. $42.12 Land Use: FR-1 Side Yard: 5!5 Cut. 1 0 1 Initial Structural: 1 $0 00 Ilan. 1ELEC./PLUMB 1 Rear Yard: 20 I Fill 1 0 1 Development NO 1 1 Total Fee Due I $42.12 Initial Geo Review $0 00 ace:- 1R3 I SSY• j 1 Total: 1 0 1 Sewer. NO Initial Grading 1 $0 00 Water: 1 NO I Type 1VN ( — —