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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 . ' l '