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Permit No. 1059100340 ANL 6 105 SAN BERNARDINO COUNTY—EPWA/LAND MANAGEMENT DEPT • OFFICE OF BUILDING AND SAFETY PERMIT APPLICATION PERMIT NBR 105 91 00340 210A 01 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL DATE 02/25/91 I ISSUE DATE 02/25/91 I PG 1 OF ' 1 PARCEL NUMBER 1017-841-16-0000 PROPOSED USE: LATTICE PATIO COVER CURRENT USE: RESIDENCE W/GARAGE 12625T I BLK I LOT I SE29 SEC I T02 NG RNG I PRCL MMAP I PRCL ACTIVITY : L820 000COMMUNITY PLAN ZONE/LAND USE DISTRICT GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS CH/PD,IL1,FR1 GH/L—M LOT DIMENSION IRREGULAR CONST TYPE VN APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER #BLDGS ON LOT 1 GROUP R3 IMAGE BUILDERS 4222 SIERRA VISTA DR PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 30-159 CHINO CA 91709-0000 STD PLAN/ICBO FHA N (714) 597 — 9549 TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER GAUGLITZ, PHILLIP AND SUE SLAB 270 .10 27.00 15967 OAK CANYON DR CHINO HILLS CA 91709-0000 CALC. VALU 1,286.82 I ADJUSTED AREA 27 (714) 597 — 3973 ITEM CNT DESCRIPTION DETAIL TOTALS JOB SITE ADDRESS RESIDENTIAL CONSTRU 47.00 15967 OAK CANYON DR ISSUANCE FEE 22.00 CHINO HILLS CA 91709-0000 TOTAL AMOUNT 69.00 CROSS STREET OAKCREEK ROAD INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER IMAGE BUILDERS GENERAL CONTRACTORS CONT000549066 4222 SIERRA VISTA DRIVE �F„,� .afj R I 0 CHINO CA 91709-0000 d u (000) 000 — 0000 0 a g ET _ Ql L k7aV:'�TiivD aHFtET�-PEF!M7i•_ _ - _ " MINIMUM SETBACK DISTANCES Al 3: .22.1des- 45 FRNT SETBACK/CENTRLINE OAK CANYON DRIVE R/W 50 20 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.ITS I NO. BEDROOMS I IREUND SID EXT. WALLS I INT. WALLS I CEILING ROOF 1 HEATING FIREPLACES WOOD METAL IMASRY PWAATER TIR I SEWER I MIN NODEPTHI S•F./100IOSIZE! NEW/REPAIR 000COMMENTS PERMIT FOR FOOTINGS 11058803466210A01, EXISTING SLAB COPY OF CONTRACTORS LICENSE 1549066 EXP. DATE 11/30/92 SUBMITTED TO S.B. AMT WAIVED .00 AMT PAID 69.00 PAYOR NAME: IMAGE BUILDERS PAID 02/25/91 RECEIPT 673 EMPL: ADAMS, C PAID BY : CHECK NBR : 2394 ICENSED CONTRACTORS DECLARATION . I HEREBY AFFIRM THAT I AM LICENSED UNDER T ROVISIONS OF CHAPTER 9 (COMMENCING WITH SEC ION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT �LICFNSE CLASS 5 LICENSE NUMBER 9611/C6- CONTRALTO TE z-ZS'q/ /\ 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 [$50011 ❑ 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 CONTRACTORIS) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW) ❑ I AM EXEMPT UNDER SEC B AND P C FOR THIS REASON OWNER DATE 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 1 POLICY NO COMPANY ❑ CERTIFIED COPY IS HEREBY FURNISHED ❑ CERTIFIED COPY IS FILED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT .PLICANT DATE ADDITIONAL REVISION CERTIFICATE OF EXEMPTION FROMWORKERS'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 THEW ER MP. ATION LAWS OF CALIFORNIA we�� PLICANT1_ DATE Gr OJ / NOTICE TO APPLICANT IF,AIe AKING 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 1 LENDER'S NAMF 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 HAVE READ THE HAZARDOUS MATERIALS QUESTIONNAIRE AND THE WORK APPLIED FOR ON THIS PERMIT ❑ IS ❑ IS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY 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 ORDINANCES AND STATE LAWS RELATING TO BUILDI INST'UCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECT•!: PUR` ES SIGNATURE OF APPLICANT OR AGENT -!1 . ,.YEO N DATE I 1 XPIRATI 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 4/90 Owner Name 6 z/ // Zp, Permit Numbili 7 'd 3 INSPECTION RECORD DATE INSPECTOR DATE l 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 3-9-q/ IA� Fireplace Bond Beam Final On Site Improvements Roof Sheathing Final Off Site Improvements Framing end Ventilation 3-'-q 1 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 (YIN) Certificate of Occupancy HA Cole �aC i 4 13` $11 m @f+ ter.° %nv was n Bas eri t8®+ v . e-n .d r SEPTIC TANK GALS SEEP PIT X LEACH LINE WIDF X LONG X DEPTH OF ROCK N W E A / S Inspector's Signature and Initials ;v; —,(- 12-(442A: 66/4 12-17589-469 Rev 3/88