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Permit No. 0358 I; 0 S - , i APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE& OCCUPANCY CITY OF CHINO HILLS BUILDING � / CLEARED BY APPLICATION TYPE NO J C ADDRESS Z J T0 G"!SJ2 b �GV�-fz.LQ, 0 F . / /(/q.2_14 o LOT 1/% BLOCK 0rRACTz iliiO OWCf� ( NER THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT O p D ADDRESS .- -n,EA 0 STRUCT Cl PLUMB 1 MECH E1 ELECT In In rn CITY aA./�Ll_,ti /17/1s / /7 Zlp PH TYPE OF PROJECT [1 NEW 11 ALTER El ADDITION ARCHITECTI � l I. LIC NO ENGINEER ❑REPAIR U CONVERT 0 DEMO r I OCCUPANCY PMT ADDRESS PROJECTLOCATION ON SIZE N - • -- DESCRIPTION I PROPERTY I IN SO FEET CITY "'AD / I ' Pp PH CONTRACTOR.V/n /,�.n Alb,..-,n 5 /A_r• LIC NO 99(323�// t I Tik ADDRESS /24.T17 -)YY/(NII e , C. {2/7!!lYJ77T t,!` 2 I I GTT 7 '/ r�►-- -,h. ZIP 4`�('7�t6( / PH / —/17r7l�Y 3 1 I CITY BUSINESS LICENSE REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION LICENSE NO EXPIRATION DATE LICENSED CONTRACTOR S DECLARATION1.1:::) /� I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section MOO of / -1 r Division 3 of the Business and Professions Code end my license is in Lull lorce and effect Lemma Clap © License Numbs. 2-/Ft- Y././ Date '-'(`4 -`b__ Contras or ADDRESS ':1 it „e n O v v— , GTY AND ZIP PHONE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a conshuchon lending agency for the performance of Ilia work for which +,' this permit is issued(Sec 1097 Civ C)Lender s Name ``{J1 Lenders Address O OWNER BUILDER DECLARATION I hereby affirm Diet I em exempt from the Contractor's License Law for the following reason ..... r�� ., ' E i i as owner of the properly or my employees with wages as their sole compensation will do the J work and the structure is nit intended or offered for sale I_P�E'•MI1/��Sa r ExpinEalmutitcrAnoti-f ..itk ❑1 as owner of the properly am exclusively conlradmg with licensed contractors to construct the DrolaclI 0 I am esempt under Sac BIPC for this reason ` O. tAs �,, \ \�_ w, Dale INITIAI al WORKERS COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sell insure or a di at cyan,I yn Compensatiipgq,+++JI-I�nsuiancee�r or a ceidllied copy thereof POLICY NO L-,/QY 7 ' COMPANY Y//CI (L- 4-vr JX DATE EXPIRES (4-11-_ 3 ` f J Certified cops hereby furnished CITY VERIFIED ❑Certified copy n filed with the city GROUP DIVISION TYPE Date APPLICANT CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE VALUATION 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 Date APPLICANT PERMIT FEES NOTICE TO APPLICANT If after making this Certificate of Exemption you should become subject ELECTRICAL I STRUCTURAL to the Workers Compensation provisions of the Labor Code you must forthwith comply with such provision or this permit shall be deemed revoked PLUMBING I GRADING 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 MECHANICAL !Y I ISSUANCE FEES HEREBY AUTHr•••IZ REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE GEO REVIEW CCV// p URN CHECK MENTIONS s • • RTY FOR INSPECTION PURPOSES /� q-Lf—9Z ISSUANCE TOTAL PERMIT//�F�E Signature d Applicant or Agent() Date / WITS OFOSSCE/� P PERMIT NUMBER) PnM pphcer;'a I Agent s Name Ll ii / �+ 7 l • • • ,11 • , , 1,1S6124:q. „ .1 :••••t: 4 ho e •04 f Jetbet ••••,...•tt-irt • etc, S Sfl tt. £ •