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Permit No. 0627 CITY OF CHINO HILLS . • COMMUNITY DEVELOPMENT 2001 Grand Avenue APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE&OCCUPANCY Chino Hills, CA 91709 ADDREING SS 1 O ilaziez' "-- %izA_LzzL_ CLEARED BY APPLI ATION TV NO �� rFo APN /0 / -69 2_�� / Q c � Z THE FOLLOWING WORK IS AUTTRIZED BY THIS PERMIT 2 > LOT BLOCK TRACT /V9.,),6/ ❑ STRUCT ❑ PLUMB ' MECH ❑ ELECT O O 31 TYPE OF PROJECT 0 NEW 0 ALTER 0 ADDITION m U) OWNER JAOv ` 0❑ REPAIR ❑CONVERT ❑ DEMO 0 OCCUPANCY PMT ADDRESS PROJECT LOCATION ON I SIZE }1261-71/(..e.,' /� DESCRIPTION PROPERTY IN SO FEET CITY /(14/14,14.40 )/_ ' q {{ 7 0� PH 1 ARCHITECT 1 I �` 1ENGINEER LIC NO 2I II I ADDRESS I I CITY ZIP PH REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION J(\ CONTRACTOR / f) //JJ q i7 f)q t,�Ii yQ 4 X 3'/i/ ti 4L7 n 4.1,,c__ (1,i,(� ( ,. ADDRESS '(,/V t'1Lµ. � `( : q{!/ T U CITY IP 7 1 Qof-, P/i/9`�[/_ CITY BUSINESS LICENSE i / 1L/U(Q�J ^_ LICENSE NO EXPIRATION DATF lam' LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of Division 3 of the Bess and Professions Code,and my license rs in full force and effect r.\,----i License CllajssJ q �`-� License Nu /J �7 U �1 / • Date C actor Lb_ if h i t• I\ ADDRESS /47.5-17d'A!i' ) /Q -lCITY AND ZIPA_ ' PHONF ` - vv ___EpERmrrizett--A OWNER-BUILDING DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason ❑ 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 ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project I u,V...1kkE. w Initial O I am exempt under Sec B&PC for this reason Date INITIAI WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certrficate of consent to self insure,or a certificate of Workers'Compe ion Insurance,or a led c y there /� / COMPANY G/ �POLICYNO -17 GROUP DIVISION TYPE ❑ Certified copy is hereby furnished DATE EXPI'ES / l'="1—791- - 0 Caddied/co/lay! f with the aty CITY v a"""‘-':9/ 65.--1"--_ VALUATION r Date APPLICANT Jr r PERMIT FEES CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSAT O( INSURANCE I certify that in the performance of the work for which this permit rs issued,I shall not employ any person in ELECTRICAL I STRUCTURAL any manner so as to become subject to the Workers'Compensation Laws of California Date APPLICANT PLUMBING I GRADING 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 the permit shall be deemed revoked MECHANICAL, I ISSUANCE FEES ± f�w. I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS i CORRECT I AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS,AND HEREBY GEO REVIEW I PLAN CHECK , AUTHO RESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROP - e' NSPECTION PURPOSES '" Ii l q/n) -r ISSU C PPR E TOTAL PER T FEE 2 G , Sgnatu of Applicant or A�ertl Datil � ` L--s-7:6,47-2 DATE OF/1Jg/�`UAA}JC r�ry^ j PERMIT NUMBER �) r Pnnt Applicant's/Agent's Name l/j( /�/ Com.— I 6 /�f 1!_ 7 WHITE-INSPECTOR/GREEN-FILE/YELLOW-FILE/PINK-OWNER/GOLD-ASSESSOR • , . _ _ . _ BUILDING ADDRESS LOT BLOCK TRACT BUILDING INSPECTIONS RECORD OWNER ADDRESS CITY ZIP PH PLUMBING DATE APPROVED/INSPR'S SIGNATURE GROUND SOIL/WATER P1 TOP OUT P2 SHOWER PAN P3 REMARKS SEWER P5 • GAS TEST P6 FINAL PLUMBING P12 MECHANICAL DATE APPROVED/INSPR'S SIGNATURE, UNDERGROUND FLOOR Ml I I • - - ROUGH M2 I I FAU,/AC M4 FINAL MECHANICAL M12 - - - ELECTRICAL DATE APPROVED/INSPR'S _ _ SIGNATURE TEMP CONSTIrPOWEFT"'''''E3'I `: '" "'�""°•"'�""" °°'"_ UNDERGROUND _ - — - - PVC-METAL -D.�'CT�;N.0 Nt E1 �.n d 7iIi R1q ROUGH WIRING RECEPT SPACING- SERVICE-CIRCUIT E2 ,� I 4 FINAL ETFI CdL""°"®----E12°1'iiii If LEC - • , -t O rF,,r`J • STRUCTURAL DATE APPROVED/INSPR'S SIGNATURE FOUNDATION LOCATION Si REINFORCED 0 UFER 0 SLAB REINFORCED O MEMBRANE':S3 - _ FLOOR FRAME/INSUL S4 MASONRY S11 I FIREPLACE Si1 I I - - ROOF FRAMING ROOF SHEATHING S5 FRAMING S6 INSULATION SOUND ENERGY S7 LATH EXTERIOR S8 LATH INTERIOR/GYPBOARD S9 APPROVED/INSPR'S SIGNATURE DATE OF ISSUANCE PERMIT NUMBER BUILDING FINAL S12