Permit No. (54) { •
105 SAN.BERNARDINO COUNTY-EPWA/LAND I1 AGEMENT DEPT
OFFICE OF BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR 105 89 00468 210A 01 I STATUS: ACTIV
THIS TS NOT A PERMIT UNTIL ISSUED
APPL DATE 03/08/89 I ISSUE DATE 03/08/89 I PG 1 OF 1
PARCEL HUMBER 1057-291-24-0000
PROPOSED USE: je
CURRENT USE: RESIDENCE W/GARAGE
TRACT
BLK
LOT
SEC
IVITY :
13393-1I 000 1029 I SW07 103S 107W I PRCL 00AP I PORCL COTMMUNITY PLANL820 ZONE/LAND USE DISTRICT GENERAL PLAN
SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS PUD
LOT DIMENSION IRREGULAR CONST TYPE VN
APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER *BLOCS ON LOT 1 GROUP R3
DOMINGUEZ, MARCO R.
17915 LARIAT DR *PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 67-179
CHINO HILLS CA 91709-0000 STD PLAN/ICBO FHA N
(714) 597 - 9429
TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN
OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER
DOMINGUEZ, MARCO R. PORCH 364 .20 73.00
17915 LARIAT DR
CHINO HILLS CA 91709-0000 CALC. VALU 3,285.00 I ADJUSTED AREA 73
1714) 597 - 9429
ITEM CNT DESCRIPTION DETAIL TOTALS
JOB SITE -ADDRESSmair RESIDENTIAL CONSTRU 53.93
1790 LARampok TOTAL AMOUNT 53.93
CHINO`HILLS% CA 91709-0000
CROSS STREET RANCHWOOD AVENUE
INSPECTN ACCESS
CONTRACTOR NAME, ADDRESS LICENSE NUMBER
DIV. OF IND. SAFETY PERMIT:
MINIMUM SETBACK DISTANCES
43 FRNT SETBACK/CENTRLINE LARIAT DRIVE R/W 50
15 REAR SETBACK/PROP LINE
5 SIDE SETBACK/PROP LINE
5 SIDE SETBACK/PROP LINE
MECHANICAL EQUIP NOT PERMITTED IN REQUIRED SIDE SETBACKS
NO. STORIES I NO. DWELLING NO. BEDROOMS FLOOR
OR
UNITS CONCRETE
EXT. WALLS INT. WALLS CEILING `V'(�' � D
DATE
ROOF HEATING FIREPLACES
W r
WOOD METAL IMASRY jk
**Q1)
PWWATER
ATIR I SEWER I MIN
NODEPTHI S.F./100IOSIZEI NEW/REPAIR
000COMMENTS
PRE ALTER DONE BY DALE BROSE.
AMT WAIVED .00 AMT PAID 53.93
PAYOR NAME: DOMINGUEZ, MARCO PAID 03/08/89
RECEIPT 1066 EMPL: STACCATO-NYARI, M
PAID BY : CHECK NBR : 837
•LICENSED CONTRACTORS DECLARATIO• • v_ , -*,,
I HEREBY AFFIRM THAT I AM LICENSED UNDER THE 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 CONTRACTOR DATE
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM THAT I AM EXEMPT FROM THE CONTRACTORS LICENSE LAW FOR THE FOLLOWING REASON(SECTION 7031.5,BUSINESS AND PROFESSIONS CODE:
ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH OR REPAIR ANY STRUCTURE, PRIOR TO ITS ISSUANCE, ALSO
REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS
LICENSE LAW[CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE]OR THAT HE OR SHE IS EXEMPT THEREFROM
AND THE BASIS FOR THE ALLEGED EXEMPTION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL
PENALTY+- OF NOT MORE THAN FIVE HUNDRED DOLLARS [$500] I.
LJ 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(SECTION 7044,BUSINESS AND PROFESSIONS CODE•THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY
WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH
IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE, IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLETION,
THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE).
❑ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC 7044,BUSINESS AND
PROFESSIONS CODE. THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO
CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW)
❑ I AM EXEMPT UNDER SEC.C. /�/� B. AND P C. FOR THIS REASON
OWN ER i f //7'� 0 / �C DATE
3
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 (SEC. 3800, LAB.C.).
POLICY NO. COMPANY
❑ CERTIFIED COPY IS HEREBY FURNISHED
❑ CERTIFIED COPY IS FILED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT
APPLICANT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS
[$1001 OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME
SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA.
APPLICANT DATE
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
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C I.
LENDER'S NAME LENDER'S ADDRESS
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
THE CALIFORNIA HEALTH AND SAFETY CODE REQUIRES A DIVISION OF INDUSTRIAL SAFETY PERMIT AS A PREREQUISITE TO PERMIT ISSUANCE UNLESS THE APPLICANT
SIGNS ONE OF THE CERTIFICATES BELOW
❑ I CERTIFY THAT NO EXCAVATION 5 FEET OR MORE FEET IN DEPTH,INTO WHICH A PERSON IS REQUIRED TO DESCEND,WILL BE MADE IN CONNECTION WITH
WORK AUTHORIZED BY THIS PERMIT,AND THAT NO BUILDING,STRUCTURE,SCAFFOLDING, FALSEWORK,OR DEMOLITION OR DISMANTLING THEREOF,WILL
BE MORE THAN 36 FEET HIGH
❑ AS OWNER/BUILDER I WILL NOT EMPLOY ANYONE TO DO WORK WHICH WOULD REQUIRE A PERMIT FROM THE DIVISION OF INDUSTRIAL SAFETY,AS NOTED
ABOVE UNLESS SUCH PERSON HAS A PERMIT FROM THAT DIVISION
DIVISION OF INDUSTRIAL SAFETY PERMIT NUMBER
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT, I AGREE TO COMPLY WITH ALL CITY AND COUNTY
INANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HER Y AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION
PURPOSES
GNATURE OF APPLICANT OR AGENT ‘........ /7,--..----,e,. > !`�rw' .--••- -f DATF
EXPIRATION AND REFUND NOTICE
APPLICATIONS FOR WHICH NO PERMIT IS ISSUED WITHIN 180 DAYS FROM THE DATE OF APPLICATION SHALL EXPIRE.PERMITS SHALL EXPIRE IF WORK DOES NOT
COMMENCE WITHIN 180 DAYS OF ISSUANCE OF SUCH PERMIT OR IF THE WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS.FEES PAID ARE NOT
REFUNDABLE AFTER 180 DAYS FROM DATE OF PAYMENT,EXCEPT FOR ERRORS IN ACCEPTANCE WHICH MAY BE REFUNDABLE UP TO ONE YEAR FROM DATE OF
PAYMENT. ALL FEES PAID MAY NOT BE REFUNDABLE
12-17588-469 Rev. 10/88
Owner Name 0J111/ rl (p q - • Permit Numb./O58170: l&Q/D,C; '
INSPECTION RECORD
DATE INSPECTOR DATE INSPECTOR
Setback Rough Plumbing
Temporary Power Shower Pan Test
Foundation Reinforcing Steel Stucco Mesh or Exterior Siding
Excavation and Forms Insulation
F.H.A. Foundation Req. Sewer
Slab Grade Interceptor
Ground Plumbing Septic Tank
Underslab Ducts Leach Line or Seep Pit
Underslab Conduit Water Service
Fireplace Foundation Lath or Drywall Nailing
Joists and Girders Gas Line Air Test
Electrical Ground Final Energy ,
Mid-Height Bond Beam Final Plumbing •
8-Foot Bond Beam Final Heating/A.C.
Final Bond Beam Final Construction
Fireplace Bond Beam Final On Site Improvements
Roof Sheathing Final Off Site Improvements
Framing and Ventilation Final Dedication
Roof Covering Final Zoning
Rough Heating Final Electrical
Electrical Service and Ground Final Gas
Rough Electrical Developer Fees Paid
WC IY/N) Ind Saf (Y/N) Certificate of Occupancy
—VI// 9 ' 2 ) 5
_!a 23- at) 4'EfPLJrcS`T ). x7E,v73 771 45-3b*9
7
EXE Ir":1j en
—ZS
SEPTIC TANK GALS. W
SEEP. PIT X
LEACH LINF WIDE
X LONG X DEPTH OF ROCK
N.
W. E.
bitAakt
S. Inspector's Signature and Initials /(//c—) s.+L/ /i ! ‘4_V
' •
12-17589-469 Rev.3/88
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