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Permit No. 6275 (2) City of *iino Hills APPI_ISION FOR Eil1II DING PERMIT Community Development 2001 Grand Avenue Chino Fills,CA 91709 Building Address: Proposed Use - St NU 57 Stre@f1KCREEK RD G/,RAGE CONVERSION TO OFFICE APN THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT Lot 391 Block Tran625 ® Struct. ❑Plumb ,__; Hech El Elect ❑ Grading Applicart ARK MANTLE St Nc3157 Stre�KCREEK RD Type of ProjcnctNew El Alter El Addition CHINO HILLS 709 Phone 606-9403 ❑ Repair ® Convert ❑ Demo ❑ Occupancy Permit l j.: OwriIM MELVIN ProjectLocation on Size T' Description I C Property in Sq Feet St NM 57 Strd@AKCREEK RD CIgIINO HILLS 293709 Phone 606-9403 3f1RAGE CONY ( 21 Engr/Arch Lic No. 2 I I St No. Street 3 I I City Zip Phone 4 I I REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION C Contractor Lic No. Sewer I Min Depth I S/F/100 I Size St No. Street City Zip Phone Cubic Yards Excavation F ill Over Excavation City Business License License No Expiration Date Licensed Contractor's 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 Dat.. Contractor - Address ,.`.____,_ City and Zip Phone Owner Builder Declaration I hereby affirm that I m-exempt from the Contractor's License Law for the following reason 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 ❑ l, 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 2 - ?� Initial ' GI—A) Workers' Compensation Declaration I hereby affirm under penalty of perjury one of the following declarations Zoning Land Use Da 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 I work for which this permit is issued Setbacks Model/Plan Ub I have and will maintain worker's compensation, as required by Section 3700 of the FY I SYS(E)10(W LaborCode, for the performance of the work for which this permit is issued My woiker's R20 I SSY compensation insurance carrier and policy number are Ins. Co.: Group/Division/Type Policy No: Exp Date. VALUATION (This dection not be completed if the permit is for one hundred doolars($100) or less) $6 516.00 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 1 te !� Signator Warning Failure to secure workers' compensation coverage is unlawful, and shall subject an Plumbing Grading employer to cnminal 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 authonze representatives of this City Issuance Approved Total Permit Fee to enter upon the above mentioned property for inspection r c $152.30 purposes. _ c} ( ' ` i/) I 5-2-- /'C' Date Issued Permit Number Signature of Appl cant or Agent Date 5/2/96 6275 FINANCE CODE CENSUS CODE34 Print Applicant's/Agent's Name •NSTRUCTION LENDING AGENCI . 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 ADDRESQ 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,FALSE WORK,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 IDS DIS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY BUILDING INSPECTIONS RECORD DATE I INSPECTOR I I DATE I INSPECTOR Setback/Location I I Rough Plumbing I I Temporary Power I I I Shower Pan Test Foundation Reinforcing Steel I I Stucco Mesh or Exterior Siding Excavation and Forms Insulation Slab Grade Sewer Ground Plumbing Soil I Interceptor Ground Plumbing Water ( I Septic Tank Underslab Ducts li I Leach Line or Seep Pit Underslab Conduit I Water Service Underslab Gas Lath or Drywall Nailing Fireplace Foundation Gas Line Air Test Joists and Girders I Final Energy Electrical Ground Final Plumbing Mid-Height Bond Beam Final Heating/A C 8-Foot Bond Beam Final Construction Final Bond Beam I Final On Site Improvements Fireplace Bond Beam I Final Off Site Improvements Roof Sheathing I Final Dedication Framing and Ventilation Final Zoning Roof Covering Final Electrical Rough Heating I Final Gas Service and Ground I Developer Fees Paid Rough Electrical I Fire Dept Approval Verified Bonding I Certificate of Occupancy Over Head Electrical I Fence Height Gates I Heater Pool Drainage SEPTIC TANK GALS SEEP PIT X LEACH LINE WIDE ' LONG X DEPTH OF ROCK N W E S Inspector's Signature and Initials _ DATE OF ISSUANCE PERMIT NUMBER