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Permit No. 6275 1 0` City of *lino Hills APP1_QTION FOR RI111_DING PF_RMIT Community Development 2001 Grand Avenue Chino Hills,CA 91709 Building Address: Proposed Use - St No157 StreePAKCREEK RD • GARAGE CONVERSION TO OFFICE APN THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT Lot 391 Block Trace 2625 ® Struct ❑Plumb ApplicantMARK MANTLE LJ Mech ®Elect ❑ Grading St No.3157 StreetOAKCREEK RD Type of ProjecID New ❑Alter 0 Addition Cit HINO HILLS Zi191709 Phone 606-9403 Li Repair ® Convert 0 Demo 0 Occupancy Permit Owne(IM MELVIN ProjectLocation on Size Description I Property in Sq Feet St No3157 StreeOAKCREEK RD CitcHINO HILLS Zi 91709 Phone 606-9403 GARAGE CONY I 210 Engr/Arch Lic No 2 I I St No. Street 3 I I City Zip Phone 4 I I Contractor Lic No. REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION ...Is) Sewer I Min Depth I S/F/100 I Size ,p. St No Street City Zip Phone Cubic Yards Excavation Fill Over Excavation City Business License License No Expiration Date Licensed Contractor's Declaration 0 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section �Q 7000 of Division 3 of the Business and Professions Code) and my license is in full force and /� effect License Class License Number l Date Contractor Address City and Zip Phone ic- Owner Builder Declaration I hereby affirm that I am exempt from the Contractor's License Law for the following reason ❑ I, as the owner of the property, or my employees with wages as their whole 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 construct the project ❑ I am exempt under Sec___, B&PC for this reason — " – "'"'""""„" Date Initial _ ... _ - -_ _. Workers' Compensation Declaration , I hereby affirm under penalty of perjury one of the following declarations ZoningI Land Use ❑a I have and will maintain a certificate of consent to self-insure for workers' RS,FR1 compensation as provided by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued Setbacks Model/Plan ❑ b I have and will maintain worker's compensation, as required by Section 3700 of the FY I SY 5(E)10(W I LaborCode, for the performance of the work for which this permit is issued My worker's RYz0 I SSY compensation insurance carrier and policy number are Ins. Co.: Group/Division/Type Policy No. Exp Date: VALUATION (This dection need not be completed if the permit is for one hundred dooiars($100)or less) $14,516 00 ❑ c I certify that in the performance of the work for which this permit is issued I shall PERMIT FEES not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code I shall forthwith comply with those Electrical $450 Structural $118.80 provisions Date __ _Signature Warning Failure to secure workers' compensation coverage is unlawful, and shall subject an Plumbing Grading employer to criminal penalties and civil 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 Mechanical Issuance $29 00 I certify that I have read this application and state that the above information is correct. I agree to comply with all City Ordinances Geo Review Plan Check and state laws and hereby authorize representatives of this City Issuance Approved Total Permit Fee to enter upon the above mentioned property for inspection DC $152 30 purposes. Date Issued Permit Number Signature of Applicant or Agent Date 5/2/96 6275 Print Applicant's/Agent's Name FINANCE CODE C4 CENSUS CODE434 (•NSTRUCTION LENDING AGENC) • 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 O 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 O 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 ,,OIS IDIS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY BUILDING INSPECTIONS RECORD DATE INSPECTOR I I DATE INSPECTOR Setback/Location I I I Rough Plumbing Temporary Power I I I Shower Pan Test I Foundation Reinforcing Steel I Stucco Mesh or Exterior Siding I Excavation and Forms li Insulation I _9 (�� Slab Grade I Sewer Ground Plumbing Soil I Interceptor Ground Plumbing Water I Septic Tank Underslab Ducts I I Leach Line or Seep Pit Underslab Conduit I Water Service Underslab Gas I Lath or Drywall Nailing Fireplace Foundation I Gas Line Air Test Joists and Girders I Final Energy I Electrical Ground I Final Plumbing I Mid-Height Bond Beam Final Heating/A C 8-Foot Bond Beam I Final Construction I / Final Bond Beam I I Final On Site Improvements / I Fireplace Bond Beam Final Off Site Improvements / li Roof Sheathing Final Dedication / I Framing and Ventilation I Final Zoning / I Roof Covering I Final Electrical / Rough Heating I Final Gas I / \ IJA// V Service and Ground I j / / Developer Fees Paid • nIRough Electrical I�J/�/.4'(r r / I Fire Dept Approval Verified / I u Bonding I l I Certificate of Occupancy /1// V , \I r• / 1 Over Head Electrical I I / IQ I \VI V' I Fence Height I I / I Q _ I/l)vI u tGates Heater / j / ' 1 1 v I 41N Pool Drainage _ - //I ,1 / I V e ('tri. -79'49 GUS eegS' C' • SEPTIC TANK GALS SEEP PIT X LEACH LINE r WIDE LONG X DEPTH OF ROCK N W E S Inspector's Signature and Initials DATE OF ISSUANCE PERMIT NUMBER