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Permit No. 0534 APPLICATI•OR GRADING AND OTHER MISCELLANEOUS •ITS CITY OF CHINO HILLS BUILDING h-� �� / CLEARED BY APPLICATION TYPE NO C ADDRESS �sq 1 pd4 Q_,D / 7,-r.47.xcJ{A. , p LOT 1 C) BLOCK TRACT Z (4777 O > OWNER kr r, c. k I THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT D ADDRESS 5--., 0) SkJt-t„- Si 1 ❑STRUCT ❑PLUMB J MECH ^ELECT _GRADING N CITY 47(.J4...40 ZIP q I''7 10L./PH ❑NEW 0 ALTER 0 ADDITION .112 SUPERVISED GRADING ARCHITECT/ UC.NO T.DUMP DEPOSIT REQUIRED ENGINEER ADDRESS 0 REPAIR 0 CONVERT 0 DEMO CUBIC YDS (� CITY ZIP PH DISCRIPTION OF WORK AND CONDITIONS OF APPROVAL •✓\`.'o[) CONTRACTOR(JroY � , l $3�t 11 /� ADDRESS q� ! Cr- .S��r--? � J�yLQ ) o) l l V LY t _) o /-/LI - �1 AJT CITY./'I V UI—fit/►'+"' ZIP 61)-JV7 PH Y2" / /'_tIJCJ f07 \ lL✓�' - /}C/YL.1.f/" 471341/ CITY BUS LESS UCENSE UCENSE NO EXPIRATION DATF � UCENSED CONTRACTOR'S DECLARATION ` I hereby affirm that I am licensed under provisions of Chigger 9(commencing with Seaton 7000 of Division 3 of the and Professions Code.and my,acrnes l force and effect License Class I�� ( License Number- Data �f��7 loll 4 Contractor ,Yo 44 t Ole ADO ES9 CITY AND ^ CITY AND ZIP )0"-/V� 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.1097,Civ C)Lender's Name Lender's Address OWNER BUILDER DECLARRION I hereby affirm that I em exempt from the Contractor's License Law for the following reason ❑I.as owner of the property,or my employees with wages as their sole compensation,wit do the work,and the structure is not intended or offered for sale "^r.•,. ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the Prom 1 ❑I am exempt under Sec B&PC for this reason .ti Date INITIAL I . t WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sett muse,or apertific of ni Com raw�rq/�c)ora copy thereof POU Y NO //L11 v 1 JI�-q I COMPANY �S'/n _A-A, ./N DATE EXPIRES `�-I -C7 I a \ ❑Certified copy is hereby furnished CITY VERIFIES I ❑Certified copyoiswith the city I Date ` 0 / '4 APPLICANT L CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION IffIRANCE I certify that in the performance of the work for which this permit is issued,I shall not employ any VALUATION person in any manner so as to become subfect to the Workers'Compensation Laws of Cakbmia Date APPUCANT PERMIT FEES NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should become subfect 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 AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS AND MECHANICALISSUANCE FEES HEREBY A TH••IZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE GEO REVIEW I PLAN CHECK MENTI•N:• •i;�.ERTY FOR INSPECTION PURPOSES /3/4/Q-�� ISSUANCE APPROVE TOTAL PERMIT FEE Signature of Applicant Agent Date ! iI L-S ! L (,,,,E OF Issumog. PERMIT NUMBER Print Applicant's I Agent s Name /47775-/5I 11.5-3 • - v•%l l.,.J_a a w...b. • • a 1 LI• 7c,c A - - .e , . w a k,• 4r 3, - .J 1' . , .5 v