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Permit No. 1069101274 Y 1106 SAN BERNARDINO COUNTY-EPWA/LAND NAGEMENT DEPT • OFFICE OF BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR 106 91 01274 201A 01 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED , ' APPL DATE 10/03/91 I ISSUE DATE 10/03/91 I PG 1 OF 1 PARCEL NUMBER. /, J PROPOSED USE: RESIDENCE / 2/ - [ �� �( CURRENT USE: VACANT TRACT 1000 10LOT 06 I SSEC W20 I 0' I o� I PRCL MAP I PRCL ACTIVITY : L831 COMMUNITY PLAN ZONE/LAND USE DISTRICT GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS CH/PD,IL1,FR1, M-H 14924 PLAN 2 10/03/91 1017-X51-39-0000 LOT DIMENSION (CONST TYPE VN APPLICANT NAME', MAILING ADDRESS, AND PHONE NUMBER *BLDGS ON LOT GROUP R3 BROCK HOME CAP CORAL RIDGE 3380 SHELBY ST *100 *PLANS RECD 0 LAND USE PLOT 0 (INDEX NBR 25-149 ONTARIO CA 91764-0600 STD PLAN/ICBO FHA N (714) 583 - 1061 TYPE I SQ. FT. I FACTOR/P.S.F. I ADJSTED AREA/VALUATN OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER BROCK HOME CAP CORAL RIDGE 1 895 1.00 895.00 3380 SHELBY ST *100 2 870 1.00 870.00 ONTARIO CA 91764-0000 GAR 494 .50 247.00 (714) 583 - 1061 PORCH 30 .20 6.00 JOB SITE ADDRESS CALC. VALU 97,691.38 I ADJUSTED AREA 2018 2540 PASEO TORTUGA . CHINO HILLS CA 91709-0000 ITEM CNT DESCRIPTION DETAIL TOTALS CROSS STREET CALLE MADRID RESIDENTIAL CONSTRU 1,240.00 INSPECTN ACCESS TOTAL AMOUNT 1,240.00 CONTRACTOR NAME, ADDRESS LICENSE NUMBER BROCK M J T SONS INC CONT000054648 6767 FOREST LAWN DRIVE LOS ANGELES ' ' CA 90068-0000 (000) 000 - 0000 CIV or IND S CCTV DE NTT. MINIMUM SETBACK DISTANCES 45 FRNT SETBACK/CENTRLINE PASEO TORTUGA 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 NO.UNIT2DWELLING I NO. BEDROOMS I CONCRETE1 4 FOOO EXT. WALLS I INT. WALLS CEILING STUCCO SHEETROCK SHEETROCK, ROOF 1 HEATING 1 FIREPLACES TILE NATURAL GAS METAL 01 IMASRY WATER PUBLIC (PUBLIC SEWER I MIN 000EPTHI S 000100I0000EI NENEWEPAIR COMMENTS AMT WAIVED .00 AMT PAID 1,240.00 PAYOR NAHE: BROCK HOMES PAID 10/03/91 RECEIPT : 00004048 EMPL: FLETS, DEBORAH PAID BY : CHECK NBR : 3496 • •CENSED 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 EFFECTFF (/f� �j/J.� LICENSE CLASS /r/ LICENSE NUMBER_,) �4 / �/ CONTRACTOR/'Irv, IJ�f�- DATE_A1,174 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 CONTRACTORISI 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 ILE WITH THE COUNTY BUILDING INSPECTION DEPARTMENT APPLICANT DATE / /l i/ld/ � � i • ADDITIONAL REVf3fON CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS _ [$1001 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 DATF 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 IS A 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 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, 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 INSPEC POSE SIGNATURE OF APPLICANT OR AGENT DATE /o 3./91 / / 1/// !,, I !/ 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 1.1..MGC And C.., A/GO ,c.oT !!// 'Owner Name C� �'�� �� � Permit Num id,.1d��7 `z INSPECTION RECORD I DATE INSPECTOR DATE I INSPECTOR _ Setback /O- /7 - 9/ 7' Rough Plumbing _t 7C1-"*".- 11Alik Temporary Power Shower Pan Test V'--- 1 - . Foundation Reinforcing Steel a 17 / ,v" S .c 41Z/D.or Exterior Siding 1 Z.-2.3 -971 Excavation and Forms ..Il� Insulation f 2 -2 O -1/I 72,14 F H.A. Foundation Req . ' Sewerkiij Ili13 749 12, '11- 4 i I /3,41 Slab Grade Interceptor Ground Plumbing A4 c to-/7 - 1 TE0,1 Septic Tank Underslab Ducts Leach Line or Seep Pi Underslab Conduit Water Service j 4 PVL /Q - 17- 9/ 754 Fireplace Foundation Lath o wall Na I Z.-X.3-47i I 11Pr( Joists and Girders Gas Line Air Test 1-f (,--- Li i4 Electrical Ground j,/-f.e - /D- 17- 11 Ttif1f Final Energy Mid Height Bond Beam Final Plumbing ,r°1 i ^ � 8-Foot Bond Beam Final Heating/A.C. . ey I r — Final Bond Beam Final Construction V V Fireplace Bond Beam l Final On Site Improvements I Roof Sheathing _jam- AV A Final Off Site Improvements Framing and Ventilation /7 L / Final Dedication \ Roof Covering ' I k/ Final Zoning ri Rough Heating „ V I kj/ Final Electrical ,vr_4�',il _O --,Et. .-!--- Electrical Service and Ground \ ./ I Final Gas L� i Rough Electrical V I/ Developer Fees Paid _ I ---WCAY/N)- — -- - -- - -- Ind-Saf (Y/A1)-- --- _- Certificate of Occupancy- - _1.2.-.41 -'11-"1-rYg"- - /.a-6- s l ,<_ ,t...�-.- ,...«:� ,o 11 /91- SEPTIC TANK GALS SEEP PIT X LEACH LINE WIDE X LONG X DEPTH OF ROCK N W E S Inspector's Signature and Initials _ /314- 12-17589-469 Rev 3/88