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Permit No. 1059100082 105 SAMBERNARDINO COUNTY—EPWA/LAND•AGEMENT DEPT S pFFICE OF BUILDING AND SAFETY P E RMI T APPLICATION PERMIT 148R 105 91 00682 205A 01 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL RATE 01/18Y9i I ISSUE DATE 01/18/91 I PG 1 OF 1 PARCEL NUMBER 1031-321-28-0000 , PROMO USE: FAIL,/ €tt1bM AbDITION (-3 :4-,( - e WORM UgE: Ofging4tt WItt] 6A0AGE 12625TRACT 1000 1331 LOT I SE29 SEC I p2 1088WW RNG I PRCL 00AP I PORCL CCT'IVIITY PPLANLi323 20fJE/L1�ND USE DISTRICT GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CH/Ark/LLS ( Ci1/PD,IL1,FR1 LOT DiIENSI0N 48 X 103 CONST TYPE VN APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER *8LDO b1 LOT 1 (GROUP R3 CONLEY, MIKE 3056 OAKCREEK RD IPLANS DECD 0 LAND at PLOT 0 (INDEX NBR 30-159 CHINO HILLS CA 91709-0000 STD OLAN%tCBO II FHA N (714) 597 - 5640 TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER CONLEY, MIKE 1 300 1.00 300.00 3056 OAKCREEK RD CHIN HILLS CA 91709-0000 CALC. VALU 14,298.00 I ADJUSTED AREA 300 (714) 597 - 5640 - ITEM CNT D1SCBIPTIC71. DETAIL TOTALS JOB SITE ADDRESS RESME IAL OONSTRU 167.00 3056 OAKCREEK RD TOtl1E AMbiNT 167.00 CHIN HILLS CA 91709-0000 CROSS STREET OAK CANYON DRIVE INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER DTV. OF IND, SAFETY PERMIT: _ _ _ MINIMUM SETBACK DISTANCES 45 FRNT SETBACK/CENTRLINE OAKCREEK RD 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. DWELLING I NO. BEDROOMS I CONCRETEO EXT. WALLS IINT. WALLS CEILING COMPLETED STUCCO SHEETROCK SHEETROCK DATE1-I/ ROOF HEATING FIREPLACES TILE I NATURAL GAS METAL IMASRY PUWATER BLIC IPUBEER IC I MIN0DEPTH' S'0000100I0000 NEW/REPAIR COMMENTS 01/18/91 MAPPED EXISTING LANDALIDE AREA. PRE ALTER DONE BY STEVE GOLDSMITH. D.FLETES. AMT {4'AI D .00 AMT PAID 167.00 0408 �: T.M.DESIGN PAID 01/18/91 RECiPt 148 EMPL: FLETS, DEBORAH PAID BY : CHECK WOO : 2856 SiCENSED CONTRACTORS DECLARATION I HEREBY AFFIRM THAT I AM LICENSED UNDER T OVISIONS OF CHAPTER 9 (COMMENCING WITH SEC 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT LICENSE CLASS LICENSE NUMBER CONTRACTOR DATE 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 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) POLICY NO COMPANY • ❑ CERTIFIED COPY IS HEREBY FURNISHED ❑ CERTIFIED COPY IS FILED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT APPLICANT DATF ADDITIONAL REVISION • CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS 01001 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 DATF 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 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 BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES SIGNATURE OF APPLICANT OR AGENT DATE 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 12-17688 469 Rev 4/90 Owner•Name • Permit NumIw59/ tee 2..o TA-0 INSPECTION RECO DATE I INSPECTOR I I DATE ( 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 Underalab 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 5- 1I-9 / 7 Fireplace Bond Beam Final On Site Improvements Roof Sheathing Final Off Site Improvements , Framing and Ventilation 1 Final Dedication Roof Covering 1 Final Zoning Rough Heating 1 Final Electrical S-3 Electrical Service and Ground 1 Final Gas Rough Electrical 1 Developer Fees Paid WC (YIN) Ind Saf (YIN) J Certificate of Occupancy RnDl FTh. U SEPTIC TANK GALS V U IV1 SEEP PIT X a 7 ) ,; LEACH LINE WIDF UIH I X LONG X DEPTH OF ROCK /b N W E L 'tel Inspector's Signature and Initials I/ .s�C.L Atsa,_t.O� /fA7 12.17589-489 Rev 3/88