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Permit No. 1285 W✓s7/ d? 47--a—' -) n-J dam. AP , CITY OF CHINO HILLS "''''• COMMUNITY DEVELOPMENT \,.., -. .- 2001 Grand Avenue APPLICATION FOR A B1j LDING PERMIT AND A CERTIFICATE OF USE&OCCUPANCY Chino Hills, CA 91709 BUILDING CLEARED BY APPLICATION TYPE NO, CO ADDRESS C �/��/J 0 APN, QQ�� Gj Z �v p�'' I1 I I. 77 7 THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT D LOT 7/ BLOCK TRACT /j�,�lg ❑ STRUCT ❑ PLUMB ❑ MECHLECT 00 vv�� / 0 77 TYPE OF PROJECT ❑ NEW ❑ ALTER ❑ ADDITION m �f fn OWNER ` w`4+ r/110 t' CI REPAIR CI CONVERT ❑ DEMO ❑ OCCUPANCY PMT )�( _ PROJECT LOCATION ON SIZE ADDRESS 1 rt I-19 ��l—L� Pi:- 1i e DESCRIPTION I PROPERTY I IN SO FEET S3,,,... CITY 6#./t49 /// , kb C ZIP qr '7/® PH q7-2o S 7 I I v ARCHITECT , I ENGINEER LIC NO 2I I ADDRESS 3 I I CITY ZIP PH REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION CONTRACTOR LIC NO 4/ 7/2 -..e.,,' ''7Z—/2 Si ADDRESS 444 f� 70 , j� \\ CITY ZIP PH kc CITY BUSINESS LICENSE LICENSE NO EXPIRATION DATPr LICENSED CONTRACTOR'S DECLARATION 1 I hereby affirm that I am 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 License Class License Number Date Contractor ADDRESS CITY AND ZIP PHONE OWNER-BUILDING DECLARATION 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 4'; ''- / B&PC for this reason �✓ Date -7 _IH-7 3 INITIAL ^g • 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 , COMPANY POLICY NO GROUP DIVISIOP TYPE/ ❑ Certified copy is hereby furnished DATE EXPIRES • ❑ Certified copy is filed with the city CITY VERIFIED VALUATION Date APPLICANT 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 L I STRUCTURAL any manner as jp bec��'2°subject to the Workers'Compensattiioonn Laws of California / Date 4 / ) APPLICANT Y� S f PLUMBING I GRADING NOTICE TO APPLICANT If,after making the Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such provisions or the permit shall be deemed revoked MECHANICAL I ISSUANCE FEES3 c j) 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 AUTHORI REPRESENTAT S OF THIS ITV T ENTER UPON THE ABOVE MENTIONED PROP FOR INSPECTI P PO ISSUANCE APPROVED' TOTAL PERMIT FEE Signature/of Applicant or,q(("�ext., • Date % • ! /47 , e ZiZ/- /4 f DATE OF ISSUANCE' PERMIT NUMBER Print Applicant's/Agent's Name / .fi(, 3 I / � G J 1/47A�• 6� v A000000 D,-c,„ 5/07m 03 Receipt i}= O000:.74 CASH RECEIVED f/69.00 Amount 7E1EYlrl X69.00 WHITE-INSPECTOR/GREEN-FILE/YELLOW-FILE/PINK-OWNER/GOLD-ASSESSOR lam • • BUILDING ADDRESS • LOT BLOCK TRACT BUILDING INSPEC_ TIONS 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 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 UNDERGROUNDVCMETAL- 7,9 PVC-METAL-D.B.0 El ,J l �? ROUGH WIRING " RECEPT SPACING- SERVICE-CIRCUIT E2 r FINAL ELECTRICAL E12 STRUCTURAL DATE APPROVED/INSPR'S SIGNATURE FOUNDATION:LOCATION 51 REINFORCED 0 UFER 0 SLAB REINFORCED MEMBRANE O S3 FLOOR FRAME/INSUL S4 I MASONRY S11 FIREPLACE S11 ROOF FRAMING ROOF SHEATHING S5 FRAMING S6 INSULATION SOUND ENERGY S7 • LATH EXTERIOR S8 • LATH INTERIOFUGYPBOARD S9 APPROVED/INSPR'S SIGNATURE DATE OF ISSUANCE PERMIT NUMBER BUILDING FINAL S12 Ic �. •