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Permit No. 1996 CITY OF CHINO HILLS 111 COMMUNITY DEVELOPMENT 2001 Grand Avenue APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE&OCCUPANCY Chino Hills, CA 91709 BUILDING 7j /,� _ C �+ J� / CLEARED BY APPLICATION TYPE NO CO ADDRESS 3 3 \ /V �. G 7_ /\ VA M+s r/ ) F VAP THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT 0 D O ,,e_-- CTRACT) ❑ STRUCT ❑ PLUMB ❑ MECH ❑ ELECT 0 II r TYPE OF PROJECT ❑ NEW ❑ ALTER ❑ ADDITION m /� � OWNER �/� O S C / 'TO r € p `C\_ C 4 L 0 REPAIR 0 CONVERT 0 DEMO 0 OCCUPANCY PMT V ADDRESS ! J ,�j S/ PROJECT LOCATION ON SIZE �' �(' el� �i v / DESCRIPTION PROPERTY I IN SO FEET (� CITY r- k ( K „( f I is ZIP PH 1 I I �`1 J\J ARCHITECT I I �L/ ENGINEER LC NO 2 ADDRESS 9 I I ` 'NC`` CITY ZIP PH REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION CONTRACTOR LIC NO ".3 s q ?Y. X / 4 fr-x/7 (l it G_"z_-- ADDRESS / 3 }. 7 /'` � S C 6...,,_ 4?-- CITY CITY ( ,/L list ZIP (] f 7( c, PH j ..2 8. rD 734 V CITY BUSINESS LICENSE t� LICENSE NO EXPIRATIONCDATE � //' /�/G 1��� / Y/, LICENSED CONTRACTOR S DECLARATION �'' `' /D/ /7/�/� / I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of Division 3 of the Business and Professions Code and my license rs in full force and effect - i License Class- C (r2 7 License Number '‘f 3 7 $ " f Date Contractor ADDRESS CITY AND ZIP PHONE OWNER BUILDING DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason O 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 ❑ I as owner of the property am exclusively contracting with licensed contractors to construd the project ❑ I am exempt under Sec B&PC for this reason Date INITIAL < 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 V COMPANY POLICY NO GROUP DIVISION TYPE ❑ Certified copy is hereby furnished DATE EXPIRES ❑ Certified copy is fled with the city CITY VERIFIED VALUATION �e di - - _ Date APPLICANT PERMIT FEES CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE /-- I certify that in the performance of the work for which this permit rs issued I shall not employ any person in ELECTRICAL I STRUCTURAL Z l . ZO any manner so as to become subject to the Workers'Compensation Laws of California ✓ Date APPLICANT PLUMBING I GRADING 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 MECHANICAL I ISSUANCE FEES, 0 , I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT I AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS AND HEREBY GEO REVIEW I PLAN CHECK AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROPERTY F R INSPEC`I0 PU POSES ISSUANCE APPROVED ,TOTAL PERMIT FEE 7'9'7-.1/ � e--w, F4 7i 3 ..-,-.?... . ....e...„, s-y z' Signature of Applicant&Agent r/ Date RA4-s z� � DATE OF ISSUANCE PERMIT NUMBER Pnnt Applicant siAgent s Name !// /f3 /7/5YG 72 _ ••"" 61/ Operator: VIRGINIA Check #: 000000000 Date: 9/16/93 00 Receipt #: 0000416 CASH RECEIVED $54.20 ,ont Tendered $100.00 WHITE-INSPECTOR/GREEN-FILE/YELLOW-FILE/PINK-OWNER/GOLD-ASSESSOR I 1 BUILDING ADDRESS LOT BLOCK TRACT BUILDING INSPECTIONS RECORD OWNER ADDRESS CITY ZIP PH • PLUMBING DATE APPROVED/INSPR'S SIGNATURE GROUND SOIL/WATER P1 TOP OUT P2 SHOWER PAN P3 REMARKS SEWER P5 GAS TEST P6 FINAL PLUMBING P12 MECHANICAL DATE APPROVED/INSPR'S SIGNATURE UNDERGROUND FLOOR M1 ROUGH M2 FAU/AC M4 FINAL MECHANICAL M12 ELECTRICAL DATE APPROVED/INSPR'S SIGNATURE TEMP CONSTN POWER E3 UNDERGROUND PVC-METAL-D B C El ROUGH WIRING RECEPT SPACING- SERVICE-CIRCUIT E2 FINAL ELECTRICAL E12 STRUCTURAL DATE APPROVED/INSPRS 7 SIGNATURE REINFORCEDFOUNDATION VII1ATIO UFER ❑Si 47/0„;/7, 3//�3 I� SLAB REINFORCE)❑MEMBRANE❑S3 FLOOR FRAME/INSUL S4 MASONRY S11 IRI' 0 FIREPLACE Si 1 I `� ROOF FRAMING ROOF SHEATHING S5 FRAMING S6 INSULATION SOUND ENERGY S7 LATH EXTERIOR SE1 LATH INTERIOR/GYPBOARD S9 • APPROVED/INSPR'S SIGNATURE DATE OF ISSUANCE PERMIT NUMBER BUILDING FINAL S12 /oA „ - 1