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Permit No. 2012-26589 6..) City of Chino Hills BUILDING DIVISION OF COMMUNITY DEVELOPMENT DEPARTMENT 14000 City Center Dr.,Chino Hills,CA91709 Counter Phone (909)3642780 Building Permit 24-Hourinspe tion Line 909)364-2790 (NOTE You must call before 3p.m.fora next business day inspection) City Hall Main Number (909)364-2600 NOTICE: THIS PERMIT BECOMES NULL AND VOID IF WORK IS NOT COMMENCED WITHIN PLEASE USE PERMIT NUMBER 180 DAYS FROM DATE OF ISSUANCE,OR IF WORK IS SUSPENDED AT ANY TIME FOR MORE BELOW WHEN MAKING INQUIRIES THAN 180 DAYS OR IF WORK IS DONE IN VIOLATION OF ANY CITY OR STATE LAWS OR REQUESTING INSPECTIONS RELATING THERETO. PROJECT DESCRIPTION PROJECT No. PERMIT No. REMOVE EXISTING TILE,INSTALL 2 LAYERS 30113 FELT;REINSTALL EXISTING TILE 15 SQUARES 2012-26589 34220 BUILDING ADDRESS I APT.f UNIT NO. ISSUED DATE ISSUED BY 15955 OAK CANYON DR 11/28/2012 Beeler,Melissa Q/ APN ITR1CT MAP# I LOT (FLOORS!UNITS I PROJECT PERMITS - I P.TYPE 103132118 CENCUS CODES (CONST.TYPE !ZONING TYPE I OCCUPANCY TYPE VALUATION 00000 I TOTAL SQFT 0001 BLDG.SQFT 434 Res Add/Alter Current Owners: - Fees Name-ANGELA LIU Fee Group/ Fee Description Fee Amount Payments Address. 15955 OAK CANYON DRIVE CHINO HILLS CA 91709 Transaction Type Ph: 626353-2536 Re-Roof _ $144.75 Email: M@CH.ORG Contractor. LA ROCQUE BETTER ROOFS INC-LA ROCQUE BETTER ROOFS,INC B001 Permit Issuance Fee $54.00 54.00 Address. 9007 ARROW RT#180 RANCHO CUCAMONGA CA 91730 839-853 Residential Structural Fee $89.75 8975 Ph. 909-476-2699 Email: - INFO@FAMILYROOFER.COM 581473 $1.00 1.00 Lie.Infornatton455Tl3 - Exp.Date:4(30/2014 LICENSED CONTRACTORS DECRATIONLICENSED CONTRACTORS DECLARATION TOTAL FEES $144.75 LA I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9(commencing AMOUNT PAID $144.75 with Sec.7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. In secunng this permit I am acting with the knowledge of and on behalf of the owner of the property. �1 / -�y-' l� /- BALANCE DUE $0.00 Date//'4y1 -/2 ContractoE �f/v/A-iwO eft 12—.C1 T740-4 IN Y OWNER-BUILDER DECLARATION 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's Licence Law for the following reason,(Sec,7031.5,Business and Profesional Code: My city or county which requires a permit to construct,alter,improve,demolish or repair any structure,pnor 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 Sec.7031.5 by any applicant fora permit subjects the applicant to a civil penalty of not more that five hundred dollars($500.00) I,as owner of the propterty,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sale(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 does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale 0 however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he 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 Contractor's 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 article 3 of the Business and Professions Code. Date. Permittee Print Full Name WORKERS COMPENSATION DECLARATION I hereby afro under penalty of penury one of the following declarations: I have and will maintain a certificate of consent to self-insure for workers'compensation,as I certify that I have read this application and state that the above information is correct I agree to comply provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is with all city and county ordinances and state laws relating to building construction,and hereby authorize issued. representatives of this city to enter upon the above-mentioned proptery for inspection purposes gI have and will maintain workers'compensation insurance,as required by Section 3700 of the /� %/� y�f- LaborCode,forthe performance of the work for which this permit Is issued My workers compensation j\b /„ +yJ sae ! N/ //' - "2_.� 2 insurance carrier and policynumberof r-arree �> ,� IYSL.(/Y�i •( # '12�{2 1C�rrrer.1-t r c.--J-r.....f/ Policy APPLICANT SIGNATURE DATE �Ij `/ Applicant DENNIS GRANT 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 worker's compensation laws of California,and Address' 9077 ARROW RTE#100 RANCHO CUCAMONGA CA 91730 agree that if I should become subject to the worker's compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with those provisions Ph- 909.376-1295 Email: M@CH.ORG Date: //�� ,r Lic.Information Exp.Date: Applicarll/'' /\V -, l'/__— __ I" I certify that the user of this facility shall comply with sections 25506,25533 and 25534 of the Health and - - Safety Code,which regulate the storage,handling and use of hazardous materials WARNING: Failure to secure workers compensation coverage is unlawful,and shall subject an employer to criminal penalities and owl fines up to one hundred thousand dollars($100,000),in addition to the cost of compensation,damages as provided for in section 3706 of the Labor Code,interest,and attorney's fees. 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