Permit No. 1058802764 (3) •
105 SAN BERNARDINO COUNTY-EPWA/LAND AGEMENT DEPT
OFFICE OF'BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR 105 88 02764 210A 01 I PAGE 1 OF 1
THIS IS NOT A PERMIT UNTIL ISSUED
AP.PL DATE 08/31/88 ISSUE DATE 08/31/88
PARCEL NUMBER 1023-371-21-0000
PROPOSED USE: PATIO
/d 3 3 7 / - CURRENT USE: RESIDENCE
12581TRAC
BLK
LOT
SEC
T 1000 1057 I SWO8 102S 08W PRCL 00AP I PRCLOACTIVITY
PLANL820 ZONE/LAND USE DISTRICT GENERAL PLAN
SUBDIVISION NAME SUBDIVISION PARCEL NO CHIN HILLS CH/PUD
LOT DIMENSION IRREGULAR CONST TYPE VN
APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER *BOGS ON LOT 1 'GROUP R3
SHORT, RICHARD A.
13426 HOWENDY CRESCENT . *PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 31-134
CHIN HILLS CA 91709-0000 STD PLAN/ICBO FHA N
(714) 590 - 8559
GRADING INITIAL ACTUAL
OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER CU.YDS. EXC.
SHORT, RICHARD A. e� � CU.YDS. FILL
13426 ENT .
CHIN HILLS CA 91709-0000 TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN
(714) 590 - 8559
PORCH 750 .20 150.00
JOB SITE ADDRESS
13426 HOWENDY CRESCENT . CALC. VALU 6,300.00 I ADJUSTED AREA 150
CHIN HILLS CA 91709-0000
CROSS STREET MITCHELL DRIVE ITEM CNT DESCRIPTION DETAIL TOTALS
INSPECTN ACCESS RESIDENTIAL CONSTRU 57.20
TOTAL AMOUNT 57.20
CONTRACTOR NAME LICENSE NUMBER
MAILING ADDRESS, PHONE NUMBER
MINIMUM SETBACK DISTANCES
45 FRNT SETBACK/CENTRLINE HOWENCY CRESCENT 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
NO STORIES I UNITS DWELLING I NO. BEDROOMS I FLOOR
EXT. WALLS I INT. WALLS I CEILING
ROOF I HEATING FIREPLACES
WO METAL IMASRY
PNNATER
ATIR I SEWER I MINODEPTHI S.F./100IOSIZEI NEW/REPAIR
COMMENTS
PRE-ALTER BY TOM BERNARD
AMT WAIVED .00 AMT PAID 57.20
PAYOR NAME• SHORT, RICHARD A. PAID 08/31/88
RECEIPT 3273 EMPL: STACCATO-NYARI, M
OICENSED CONTRACTORS 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 • 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 ($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 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 I
POLICY NO COMPANY
❑ CERTIFIED COPY IS HEREBY FURNISHED
❑ CERTIFIED COPY IS FILED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT
APPLICANT DATE
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 THE WORKERS' COMPENSATION LAWS OF CALIFORNIA
APPLICANT DATE
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 ISA CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C I
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 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 NOTICE
APPLICATIONS FOR WHICH NO PERMIT IS ISSUED WITHIN 180 DAYS FOLLOWING THE DATE OF APPLICATION SHALL EXPIRE,EVERY PERMIT 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 ONE YEAR FROM DATE OF PAYMENT, ALL FEES PAID MAY NOT BE REFUNDABLE
12-17588-469