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Permit No. 0109 011) • 7. r . r x • , , • APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE & OCCUPANCY CITY OF CHINO HILLS BUILDING ADDRESS ;olio op cpNyo4 . //fD �i� i/S CA CLEARED BY APPLICATION TYPE NO - r O LOT BLOCK TRACT 2 3. OWNER I\'J m F NG\c__J , THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT 0 0 33 ADDRESS" -aO-78 OPNC- C-S) .%)tD. \ LfOQC- ❑STRUCT 0 PLUMB 11 MECH fl ELECT y CITY Gil N,10 H 1 l is CP ZIP G 1709 PH Col TYPE OF PROJECT U NEW 11 ALTER 11 ADDITION ARCHITECT/ LIC NO ENGINEER ❑REPAIR U CONVERT U DEMO 11 OCCUPANCY PMT ADDRESS PROJECT' LOCATION ONSIZE 1 -- DESCRIPTION PROPERTY I IN SO FEET �J CITY ZIP PH CONTRACTOR LIC NO I ( I ADDRESS 2 I I - - - CITY ZIP PH , CITY BUSINESS LICENSE REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION LICENSE NO EXPIRATION DAIc LICENSE()CONTRACTOR S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 04 /I X J --?e;A 7-/o Division Cl the Business and Professions Code,and my license is in lull force end effect \ ., LKXeae Claes License Number -.�\ Dee, Contractor ADDRESS CITY AND ZIP PHONE CONSTRUCTION LENDING AGENCY I hereby affirm Thal there is a construction lending agency for the performance of the work for which Cit.this permit is issued(Sec 1097 C C(Lender's Name \ Lender s Address -..„..7. OWNER BUILDER DECLARATION I hereby affirm that I em exempt from the Contractors License Law for Me lollosnng reason 9/1 I es owner of the property or my employees with wages es their sole compensation,will do the - ir ��-_ work,and the structure a not intended or offered for sale '" 0 f as owner of the property am exclusively contracting with licensed contractors to construct the ~ °'°'°`t PERMIT ExpIR 0 I am exempt under Sec B&PC for this reason - Date INITIAL WORKERS COMPENSATION DECLARATION awy.�`'�\ `` -....N.I hereby affirm that I have a certificate of consent to sett insure ore certificate of Workers —wV�*i1'--~, '-.Inttl \,. a I[ Compensation Insurance or a certified copy thereof POLICY NO I COMPANY DATE EXPIRES (J Certified copy is hereby furnished CITY VERIFIED 0 Certified copy is tiled with the city GROUP DIVISION TYPE Date APPLICANT CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE VALUATION I certify that in the performance of the work for which This permit is issued,I s II not employ any Vperson in any manner so as to become subject to the Workers Com e�nsa/tio of California Dere -7—/7`S'? APPLICANT f /� /�7-- PERMIT FEES i NOTICE TO APPLICANT If after making this rtihcate_ol-KBmp i n should become sublecl ELECTRICAL I STRUCTURAL to the Workers Compensation provisions of the Labor Code you st forthwith comply with such provision or This perm!shall be deemed revoked PLUMBING GRADING 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 MECHANICAL ISSUANCE FEES HEREBY AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE GEO REVIEW I PLAN CHECK MMEENTIONEDD PP OPERRTYY FF} INSPECTION PURPOSES {� � /lam fir—� -7 -/7-S� I A� TOTAL PERMIT FEE /) �re df kpplicml Agen(7 Date SSu / / 1 // DATE OF ISSUAFfE / PERMIT NUMBER Prim Applicant's/Mewl s Name 7 /7/q l/ /_7/O g r ( 1 • --- • - t1.4 0.4,r-Ar_ , a Na ^T, ••••.••• z',44 t. • ". „, • 1r Tv