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Permit No. 1069100033 _ ' r ,-1111F 1111 , 106 SAN BERNARDINO COUNTY-EPWA/LAND GEMENT DEPT OFFICE OF BUILDING AND SAFETY PERMIT APPLICATION PERMIT NBR 106 91 00033 205A 01 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL DATE 05/06/91 I ISSUE DATE 05/06/91 I PG 1 OF 1 PARCEL NUMBER 1023-151-23-0000 PROPOSED USE: ROOM ADDITION CURRENT USE: RESIDENCE W/GARAGE 1TRACT I BLK000 I 024LOT I SEC SECT I (S I RNG I PRCL 0 P I PRCL ACTIVITY : L823 130 COMMUNITY PLAN I ZONE/LAND USE DISTRICT' GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CH/PD,IL1,FR1 GH/M-H LOT DIMENSION IRREGULAR CONST TYPE VN APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER *BLDGS ON LOT 1 GROUP R3 V MARTIN-SZENTMARTONI 1848 W 11TH ST *PLANS RECD 2 LAND USE PLOT 0 INDEX NBR 24-129 -UPLAND CA 91786-0000 STD PLAN/ICBO FHA N ' (714) 949 - 6806 TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN ' OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER ROTH, DARRYL 1 220 1.00 220.00 12961 OAKLAND WAY ' CHINO HILLS CA 91709-0000 CALC. VALU 10,485.20 I ADJUSTED AREA 220 (714) 628 - 1805 - ITEM CNT DESCRIPTION DETAIL TOTALS JOB SITE ADDRESS RESIDENTIAL CONSTRU 143.00 12961 OAKLAND WAY TOTAL AMOUNT 143.00 t. CHINO HILLS CA 91709-0000 CROSS STREET COTTONWOOD TRAIL INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER DIV. OF IND. SAFETY PERMX __ MINIMUM SETBACK DISTANCES , 45 FRNT SETBACK/CENTRLINE OAKLAND WAY R/W 50 15 REAR SETBACK/PROP LINE 5 SIDE SETBACK/PROP LINE 5 SIDE SETBACK/PROP LINE MECHANICAL EQUIP NOT PERMITTED IN REQUIRED SIDE SETBACKS m0. STORIES I NO. DWELLING I NO. BEDROOMS I FLOOR -- , EXT. WALLS INT. WALLS ' CEILING , ROOF HEATING FIREPLACES (METAL IMASRY 4 - :._ -WATERN DEPTH F./100 SIZE NEW/REPAIR ' PUBLIC 000 SEWER I MI000 .I S.000 (0000 ONTARIO cot IENrs - COMPLEX I/ CwHi //2,72,0 DATE i AMT WAIVED .00 AMT PAID 143.00 PAYOR NAME: JEFFREY SZENTMARTONI PAID 05/06/91 RECEIPT 1723 EMPL: ADAMS, C _PAID B5 : CHECK NBR : 1082 k ICENSED CONTRACTORS DECLARATION /1i ,, I HEREBY AFFIRM THAT I AM LICENSED UNDER ROVISIONS OF CHAPTER 9 (COMMENCING WITH SE N 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT / /(4 / 4 (/ LICENSE CLASS Q LICENSE NUMBER b�L ( CONTRACTOR S2-6•"14012:70).' DATE / b / v1rr,� \ 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 ($500]) ❑ 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 CONTRACTORIS) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW) ❑ I AM EXEMPT UNDER SEC B AND P C FOR THIS REASON OWNER DATF 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 DATE ADDITIONAL REVISION CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($100] 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 T I �ORRKERSCOMPENSATI OF CALIFORNIA PLICANT 'C) \\�� ��'nLJ-. DATE Si l7 I U 111 c I., NOTICE TOA ICA FTER 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 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 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, 1 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 INSPE ION PURPOSE /L GIGNATURE OF APPLICANT OR AGENT , w`0 \—L� DATE S/. '�+ (�( Ir v•-..Y 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 4/90 Owner r me FA-7N. 4a� �yL-' Permit Numt ‘9/ 3 L' i9o/ INSPECTION RECORD DATE I INSPECTOR I - I DATE I INSPECTOR Setback VviaKtoe OlefanrecP ,c-y-f/ 101 .-- Rough Plumbing I I Temporary Power Shower Pan Test II(--).-7Foundation Reinforcing Steel 5'-9— ' `, Stucco Mesh or Exterior Siding I 6., - 7..--k( I_-7' Excavation and Forms cj--y_Pemay; Insulation -'.c'( ��s F.H A Foundation Req Sewer U r Slab Grade 5-9-9/ eti71.r— Interceptor I Ground Plumbing • Septic Tank I Underslab Ducts Leach Line or Seep Pit I Underslab Conduit Water Service I Fireplace Foundation Lath or Drywall Nailing I Co-/y-- 9/ i157/--•.,.- Joists and Girders Gas Line Air Test I Electrical Ground Final Energy (y✓/I /� Mid-Height Bond Beam Final Plumbing I //q /� 8-Foot Bond Beam Final Heating/A.C. I(�"�" //j Final Bond Beam / Final Construction IY I,r Fireplace Bond Beam / , Final On Site Improvements 1 Roof Sheathing l , , 4 /I_ Z Final Off Site Improvements I Framing and Ventilatiory' /_, /77/ Final Dedication I Roof Covering " I v I L- Final Zoning I Rough Heating / I I Final Electrical I qk' 2.—g/ n--- 7 Electrical Servicland Ground I I Final Gas I Rough Electric/ I I Developer Fees Paid WC (YIN) / -- Ind Sat (YIN) - Certificate of Occupancy 17-�9-5 ' 40-7,z47 7 0- 7J `r7- ,3,r'.�1� / SEPTIC TANK GALS. SEEP PIT X LEACH LINE WIDF X LONG X DEPTH OF ROCK N. O G COMPLETED W E DATE K=9./ S Inspector's Signature and Initials /15 ::%1P--r- / 12.17589-469 Rev 3/88