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Permit No. 0557 CITY OF CHINO HILLS110 lir COMMUNITY DEVELOPMENT 2001 Grand Avenue APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE&OCCUPANCY Chino Hills, CA 91709 0 i A BUILDING god, CLEARED BY A LI O PE NO co f/ ADDRESSO L—fi- Sit 11 f. l O 1 n l� F761 0 r APN /5/ 7,_ ® —�C�7. f THE FOLLOWING WORK IS AUTHORIZED BY THISyERMIT O Q > LOT y A/ BLOCK TRACT i 379 Z ❑ STRUCT ❑ PLUMB ❑ MECH it,ECECT 0 11 TYPE OF PROJECT (SNEW ❑ ALTER ❑ ADDITION m CO OWNER ) ❑ REPAIR ❑ CONVERT ❑ DEMO ❑ OCCUPANCY PMT N ADDRESS PROJECT I LOCATION ON I SIZE (ZO kI Qtn.1�> f CQ p 1 ,, Pp 0 DESCRIPTION PROPERTY IN SO FEET Al' I v / -�li� �7/ /41 A �) CITY N�)��1 I2*u ZIP 0 Z(a(o 0 PH 714/7/0040- 1• f✓ ter_ a\ L /41 —0n ARCHITECT 'C ENGINEER j VA LIC NO. 2. ADDRESS 3' CITY ZIP PH REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION —��(I CONTRACTOR( ` 1 Holm.ec 1hi LIC NO ����/ 7 i�- / n /� 7'�jn,v ADDRESS /\I lJ� l!/U® - tom V - �ti� i/� � }C(/� _ (qv ju��etA.)POrT cP%vr-f-1-- t '' S-4QL CITY j/}I.�pnrt g/Ach ZIP JJ Z(//6,0 PH 7/7/76O.14sSr 7--:-?el -t.,AA-tei-e- CITY BUSINESS LICENSE NO 0/SO C EXPIRATION DATE LICENSE Ara-- aLICENSED CONTRACTOR'S DECLARATION ✓ r\V) I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of Division 3 of the Business2and Professions Code,and my license is in full force and effect License Class 1$ License Number 5553©,(I _rn� Date 10l �� 11 Z Contractor C()spa 1r�h1 I-4U]' s I4�( / /02/// "e---4 ' v ADDRESS (,x27) 1t;etn.l pc r O..'vy1 -e,y- Ori v- /4QO CITY AND ZIP�QWpt) t J OPHONE 714/740 /`K�/ OWNER-BUILDING DECLARATION J 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 project • ❑ I am exempt under Sec B&PC for this reason Date INITIAL WORKERS'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 a� �) P cz COMPANY neEIAt(L&IT(t'i44 Pg'r' KATIC/Y POLICY NO L JZS LI-2-54 J Z GROUP DIVISION TYPE 0 Certified copy is hereby furnished DATE EXPIRES 1243!!`7 Certified copy is filed with the city CITY VERIFIFfl VALUATION Date 10120 q2- #. / APPLICANT if .i i _ r i• 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 A/'] s a I STRUCTURAL any manner so as to become subject to the Workers'Compensation Laws of California Gv/ !1 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 this permit shall be deemed revoked MECHANICAL I ISSUANCE FEES 4,6 / 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 "../.1 I PROPERTY FOR //INSPECTION PURPOSES ISSUANC ROV / I TOTA F iA /'� IT FEE ,r,. Signature of/�pphcant or Agef Date / �l DATE OF IS ANCE U PERMIT NUMBER ci,'A4'5 bGame' X15 I /0 / c I 25 7 , Print Applicant's Agent's Name ` 2 ,,,zn ,,//r i - 77,,, I I WHITE-INSPECTOR/GREEN-FILE/YELLOW-FILE/PINK-OWNER/GOLD-ASSESSOR 6 . BUILDING ADDRESS • • LOT BLOCK ,, • TRACT BUILDING-INSPECTIONS RECORD. OWNER ••i •1 ADDRESS CITY ZIP PH. - - - PLUMBING DATE APPROVED/INSPR'S ^ SIGNATURE ' GROUND SOIL/WATER P1 TOP-OUT P2 - . - SHOWER PAN P3 REMARKS 1 SEWER P5 I--: GAS TEST P6 . _ FINAL PLUMBING P12 _ ._ _ MECHANICAL DATE APPROVED/INSPR'S - -- - • - - - - - - - - - -- - ----- SIGNATURE UNDERGROUND FLOOR • M1 ' • • ROUGH M2 _ FAU/AC M4 'FINAL MECHANICAL M12 _ _ - ' ELECTRICAL , DATE • APPROVED/INSPR'S _ - - __ SIGNATURE TEMP CONSTN.POWER E3 UNDERGROUND - . - - -• •- - PVC-METAL-D.B.C. El ROUGH WIRING RECEPT.SPACING- SERVICE-CIRCUIT E2 • ► 1 / FINAL ELECTRICAL E12 I /02270e I ter` STRUCTURAL DATE APPROVED/INSPR'S SIGNATURE FOUNDATION:LOCATION 51 REINFORCED 0 UFER 0 SLAB REINFORCEDO MEMBRANE S3 FLOOR FRAME/INSUL. S4 I _ . . MASONRY S11 I _. FIREPLACE S11 I --- - ----- ---- - • • - ROOF FRAMING ROOF SHEATHING S5 - FRAMING S6 I 1 INSULATION SOUND ENERGY S7 LATH EXTERIOR S8 LATH INTERIOR/GYPBOARD S9 I APPROVED/INSPR'S -SIGNATURE DATE OF ISSUANCE PERMIT NUMBER BUILDING FINAL •, S12 - - - --- - -- - - -- } , \ • r, - - - . . .