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Permit No. 1069101277 S 106 SAN BERNARDINO COUNTY-EPWA/LAND MANAGEMENT DEPT OFFICE OF BUILDING AND SAFETY P E RMI T APPLICATION PERMIT NBR 106 91 01277 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 PARC NUMBER i / / /. - [.�q_- L/S PROPOSED USE: RESIDENCE Ul /7 kc l CURRENT USE: VACANT 14924TRACT 1 BLK 000 1 LOT 010 I SEC SW20 I � 108W I PRCL MAP I PRCL ACTIVITYY PLANL831 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 1017-151-39-0000 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 3100 ;PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 25-149 ONTARIO CA 91764-0000 STD PLAN/ICBO FHA N (714) 583 - 1061 h 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 3100 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 2572 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 OF IND. SAFETY OEQMIT: - -- - - -- --- - - - - -- - - - - - -- MINIMUM SETBACK DISTANCES 55 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. 2IT DWELLING I NO. BEDROOMS I CONCRETE1 4 OOO EXT. WALLS INT. WALLS CEILING STUCCO I SHEETROCK SHEETROCK OW AR* ROOFHEATING FIREPLACES TILE I NATURAL GAS METAL 01 IMASRY CQMPLETEDZ 1-2[3::_----- WATERSEWER MIN DEPTH S.F./100 SIZE NEW/REPAIR DATE ---s° - PUBLIC (PUBLIC I 000 I 000 10000 I NEW / COMMENTS ti ' AMT WAIVED .00 AMT PAID 1,240.00 PAYOR NAME. BROCK HOMES PAID 10/03/91 RECEIPT : 00004048 EMPL: FLETS, DEBORAH PAID BY : CHECK NBR : 3496 ICENSED CONTRACTORS DECLARATIONS 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 �/ f� /� l LICENSE CLASS #I/ LICENSE NUMBER �/% `J T ,r / CONTRACTOR /1/ O DATE /a/3/f'I / 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 ($5001 1 ❑ 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 DATF 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 1 POLICY NO COMPANY ,❑,, CERTIFIED COPY IS HEREBY FURNISHED LfJ" RTIFIED COPY I ED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT• APPLICANT Y/�"' DATE /940.4��1/ ADDITIONAL REVIS CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS [51001 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 1 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 INSPECTION SIGNATURE OF APPLICANT OR AGENT DATE 1/4/07/t/ / / // // C/ E9CP!RATION 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 12 17588-469 Rev 4/90 r. :-'Owner Name ?A/ ,C-i-A s Permit Num�6' ,/47 7 i / INSPECTION RECORD DATE I INSPECTOR DATE INSPECTOR Setback (O-2/- 9 / Rough Plumbing I .4.q- - Temporary Power Shower Pan Test a......!..!.......- (�% Foundation Reinforcing Steel C1/ ( Stucco Mesh or Exterior Siding T Excavation and Forms1 -' . $Insulation f g•;c,_ Z S Z 574. F H A Foundation Req. 1� V'' Sewer Slab Grade Interceptor Ground Plumbing 4g S /0- 2 /- q/ 3i4 Septic Tank Underslab Ducts Leach Line or Seep Pit Underslab Conduit Water Service /`f Nva ( _ ) $ -9t Fireplace Foundation Lath o vwal a I - `- c A 1 714 Joists and Girders Gas Line Air Test i_ Z 7 -5 j„ elfridfrl Electrical Ground (A.4.,,,,, to -Z (-9/ er1)1Final Energy 1A* Mid-Height Bond Beam Final Plumbing r)� 8-Foot Bond Beam Final Heating/Aa . ;7 1/ Final Bond Beam Final Construction V Fireplace Bond Beam Final On Site Improvements Roof Sheathing A Z1 Final Off Site Improvements Framing and Ventilation 417 , 7' Final Dedication Roof Covering ,,/ A Ak, Final Zoning Rough Heating 14Final Electrical 104A J Electrical Service and Ground xry JrFinal Gas Rough Electrical 7 V Developer Fees Paid WC (YIN) _ _ -Ind Saf (Y/N) ---Certificate of-Occupancy --- 2=zl•=1-Z-- -7714--- - I z--CO - 9/ r4 -L. 5 - Q K. 53-44- . ON IN .rr SEPTIC TANK GALS Uw'► �/`tf SEEP PIT X LEACH LINF WIDF X LONG X DEPTH OF ROCK N W E S Inspector's Signature and Initials .A.4.rt-1..rY 754- 12-17589-469 a'1'12-17589-469 Rev 3/88