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Permit No. 1058901516 (2) 105 SAN BERNARDINO COUNTY-EPWA/LANDAGEMENT DEPT 4111 OFFICE OF BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR 105 89 01516 T30A 01 I STATUS: ACTIV THIS IS NOT A PERPIIT UNTIL ISSUED APPL DATE 05/15/89 I ISSUE DATE 05/15/89 I PG 1 OF 1 PARCEL NUMBER 1017-831-13-0000 PROPOSED USE: PRECONSTRUCTION RET WALL CURRENT USE: RESIDENCE H/GARAGE TRACT 1000 13LOT 40 I SSEC E29 102S 108W I PRCL MAP I PRCL ACTIVITY : L874 COMMUNITY PLAN ZONE/LAND USE DISTRICT GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS PUD LOT DIMENSION IRREGULAR CONST TYPE APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER *BOGS ON LOT 1 GROUP BARNES, GARY AND DELORES 3102 OAK CREEK RD *PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 31-160 CHINO HILLS CA 91709-0000 STD PLAN/ICBG FHA (714) 597 - 2557 ITEM CNT DESCRIPTION DETAIL TOTALS OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER PRE-CONSTRUCTION IN 20.26 BARNES, GARY AND DELORES TOTAL AMOUNT 20.26 3102 OAK CREEK RD CHINO HILLS CA 91709-0000 (714) 597 - 2557 JOB SITE ADDRESS 3102 OAK CREEK RD CHINO HILLS CA 91709-0000 CROSS STREET OAK HILL DRIVE INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER DIV. OF IND. SAFETY PERMIT: MINIMUM SETBACK DISTANCES 15 REAR SETBACK/PROP LINE 10 SIDE SETBACK/PROP LINE W 5 SIDE SETBACK/PROP LINE E MECHANICAL EQUIP NOT PERMITTED IN REQUIRED SIDE SETBACKS NO. STORIES I NO. DWELLING I NO. BEDROOMS I FLOOR UNITS EXT. WALLS I INT. WALLS I CEILING ROOF I HEATINGI FIRELACES METAL IMASRY ON WATERSEWER MIN DEPTH S.F./100 SIZE NEW/REPAIR TMJ, PUBLIC (PUBLIC I 000 I 000 10000 I COP COMMENTS ;, ,. ? . , � ?, e -rCY AMT WAIVED .00 AMT PAID 20.26 PAYOR NAME: GARY/DELORES BARNES PAID 05/15/89 RECEIPT 2701 EMPL: ROTRUCK, S PAID BY : CHECK NBR : 259 a .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 [$5001 I 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 I UNDER SEC B AND P C FOR THIS REASON ` )(OWNER /i f //� 14.2--c// DATF J'� /��� 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 I POLICY NO COMPANY ❑ CERTIFIED COPY IS HEREBY FURNISHED ❑ CERTIFIED COPY IS FILED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT APPLICANT DATF 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 THEWOERS' COMPENSATION S OF CALIFORNIA4. ` APPLICANT `I_ �ZC—� /� DATF �� J 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 ISA CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C I 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 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 BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION URPO ES / f /( v�/J f 3Q S ---.7 - DATE L 'SCS 9 IGNATURE OF APPLICANT OR AGENT _ rvS 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