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Permit No. 1058900557 • 105 SAN BERNARDINO COUNTY-EPWA/LAND NAGEMENT DEPT 1111 • • OFFICE OF BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR l05 89 00557 210A 02 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL DATE 03/30/89 I ISSUE DATE 03/30/89 I PG 1 OF 1 PARCEL NUMBER 1017-841-22-0000 PROPOSED USE: LATTICE PATIO COVER WN I CURRENT USE: RESIDENCE 12625TRACT 1000 I LOT 322 + SEC SE29 I 0 S t 08W J PRCL 00AP OPRCL ACTIVITY L820 I I COMMUNITY PLAN ZONE/LAND USE DISTRICTI GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS CH/PUD LOT DIMENSION IRREGULAR CONST TYPE VN APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER #BLDGS ON LOT 1 GROUP R3 SIMENTAL, JOSE F. 15931 OAK CANYON DR *PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 30-159 CHINO HILLS CA 91709-0000 STD PLAN/ICBO FHA N (714) 597 - 8312 OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN SIMENTAL, JOSE F. PORCH 154 .20 31.00 15931 OAK CANYON DR CHINO HILLS CA 91709-0000 CALC. VALU 1,395.00 I ADJUSTED AREA 31 (714) 597 - 8312 ITEM CNT DESCRIPTION DETAIL TOTALS JOB SITE ADDRESS RESIDENTIAL CONSTRU 35.45 15931 OAK CANYON DR ISSUANCE FEE 16.96/i CHINO HILLS CA 91709-0000 TOTAL AMOUNT 52.41 CROSS STREET OAKCREEK RD INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER DIV. OF IND. SAFETY PERMIT: MINIMUM SETBACK DISTANCES 45 FRNT SETBACK/CENTRLINE OAK CANYON DR R/W 50 20 REAR SETBACK/PROP LINE 40 SIDE SETBACK/CENTRLINE OAKCREEK RD R/W SO 5 SIDE SETBACK/PROP LINE MECHANICAL EQUIP NOT PERMITTED IN REQUIRED SIDE SETBACKS NO. STORIES I NO.UNITDWELLING I NO. BEDROOMS. I CONCRETE EXT. WALLS INT WALLS I CEILING ROOFHEATING FIREPLACES WOOD I (METAL IMASRY WATERSEWER MIN DEPTH S.F./100 SIZE NEW/REPAIR ONTARIO PUBLIC I I 000 I 000 10000 I COMMENTS COMPIFTED PRE-ALTER BY W.BAKER ON 3/29/89 PRE-CONSTRUCTION IS ACTIVE DATE: t z-6, -1U --)tqPik AM1 WAIVED .00 AMT PAID 52.41 PAYOR NAME: JOSE F. SIMENTAL PAID 03/30/89 RECEIPT 1597 EMPL: LUCAS, C PAID BY • CHECK NBR : 0235 • •ICENSED CONTRACTORS DECLARATION • 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 DATF 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 135001 ) XI,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 WITHTRACTOR(S) L SED PURSUANT TO THE CONTRACTORS LICENSE LAW) ❑ I EXE UNDER SEC �� B AND P C FOR THIS REASON 2�� `�j J NER L' G '/f Z DATF J '`/!/ X / 1 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) 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:MOREr�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 P. ii AS OWNER/BUILDER I WILL NOT EMPLOY'ANYONE0TO�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 t t' DIVISION OF INDUSTRIAL SAFETY PERMIT NUMBER ' ' I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABO B INFORMATION IS CORRECT, I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION D HEREBY AUT IZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOV ENTIONED PROPERTY FOR INSPECTIO PURPOSES •_ 1„,.% NATURE OF APPLICANT OR AGENT ,, �_ r% 914-79 / DATE 3-5/9-52,9 // 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 �/^ -e,--•4A- USC { Permit Num G1 S ] G U S7)- 7 -G 9-- INSPECTION RECORD DATE INSPECTOR I DATE I INSPECTOR Setback f Z,.-4---*, . Xi" 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 /2 _C--9D 7 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 /Z (� -9O ->026- Fireplace i - Fireplace Bond Beam Final On Site Improvements Roof Sheathing Final Off Site Improvements Framing and 4Leaiaai+en l G—50 -)-74441-- Final Dedication Roof Covering Final Zoning Rough Heating Final Electrical Electrical Service and Ground Final Gas Rough Electrical Developer Fees Paid WC (YIN) Ind Saf (Y/N) Certificate of Occupancy SEPTIC TANK GALS SEEP PIT X LEACH LINF WIDE X LONG X DEPTH OF ROCK Ill IFN u • . 14% AR KMme W E IVA a I /2.-&-IAP S Inspector's Signature and Initials L—+C /. 12-17589 469 Rev 3/88 ' '