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Permit No. 2273 I CITY OF CHINO HILLS • • COMMUNITY DEVELOPMENT 2001 Grand Avenue APPLICATION FOR A BUILDING PERMIT AND A CERTIFICATE OF USE &OCCUPANCY Chino Hills, CA 91709 BUILDINGCLEARED APPLICATION TYPE NO CO ADDRESS �b Q$. ICIB f5C.0 7O V 4110,Ct - /// o .49c--1 ` ��/ / � / Z A„ ,O ( Ai — �l / /`7 7E�f' THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT 2 OT BL RAC ❑ STRUCT 0 PLUMB 0 MECH 0 ELECT >O 0 TYPE OF PROJECT 0 NEW 0 ALTER 0 ADDITION m (� 1 e gfn OWNER I U i(1 tt.Z1 r,„cy Vyi ..e1/l VAD p`A ISL 5- 0 REPAIR ❑CONVERT 0 DEMO ❑ OCCUPANCY PMT V) ADDRESS 2 Og Pu 5eC) -70(:+1 , �.- PROJECT LOCATION ON SIZE {�-� 1 J T l.�C� �''7�(� DESCRIPTION // PROPERTY/� )/ IN SO FEET CITY C�'lino r r It' ZIP G '1 UH 59-7 r�7�J k? 1p�7/�tJI /C/ N/� I/�� — R:1(..) ARCHITECT ENGINEER LIC NO 2 ADDRESS 3I I CITY ZIP PH REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION . .J CONTRACTOR LIC NO //_ �_ L_/ ADDRESS CITY ZIP PH CITY BUSINESS LICENSE ` LICENSE NO EXPIRATION DATF LICENSED CONTRACTORS DECLARATION 4 //A I I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of 7 / //' /J/��L� // `v Division 3 of the Business and Professions Code and my license is n full force and effect /I,/li(j�f(i 1 ^\� License Class License Number Date Contractor ADDRESS f CITY AND ZIP PHONE OWNER BUILDING DECLARATION I hereby affirm that I am 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 will do the work and the structure is not intended or offered for sale as owner of the property am exclusively contracting with licensed contractors to construct the project ❑ I am exempt under Sec �-BBPC for this reason Datel/ L i f t csi q_ INITIAL4_U...- y 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 COMPANY POLICY NO GROUP /V / DIVISION TYPE //�1 ,/ ❑ Certified copy is hereby furnished DATE EXPIRES *.e...,../2/(4, }, /� L, _v/N ❑ Certified copy is filed with the aty CITY VERIFIEn� VALUATION yy� ^ 2/ /O �/0 ' Date APPLICANT PERMIT FEES CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE I certify that in the performance of the work for which this permt is issued I shall not errploy any person in ELECTRICAL I STRUCTURAL 71.4t.-43)) any manner so as to become subject to the Workers Compensation y��Laws of Cal�rni Date III ICS /`�7 APPLICANT' ///..j' �' 4%4P 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 D� - this permit shall be deemed revoked MECHANICAL ISSUANCE FEES�9 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 HEREBY GEO REVIEW I PLAN CHECK AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPE ION PURPOSES ISSUANCE APP OVED-_ � TOTAL PERMIT FE ���) PK 1/4 /' � � 'II i`/J/J G�y/// l�(� - ISignature of Applicant or Agent Date M'aitibt 1141g4 Itej DATE//SUAJJ%//e3 I PERMIT NUMBER 7� Pnnt Applicant&Agent s Name ,,...:•").,7) �`� J d- , 7 //t7- tJCL.'I . : V:.BL1:I dict{: ; CCCCC j,,•rE Ditto; >.:id/:: 00 iecel2t ;to 00O0STD ChECK WHITE-INSPECTOR/GREEN-FILE/YELLOW-FILE/PINK-OWNER/GOLD-ASSESSOR • S 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 ROUGH M2 FAU/AC M4 FINAL MECHANICAL M12 ELECTRICAL DATE APPROVED/INSPR'S SIGNATURE TEMP CONSTN POWER E3 UNDERGROUND PVC-METAL-D B C El ROUGH WIRING RECEPT SPACING- SERVICE-CIRCUIT E2 FINAL ELECTRICAL E12 STRUCTURAL DATE APPROVED/INSPR'S SIGNATURE FOUNDATION LOCATION Si REINFORCED ❑ UFER ❑ SLAB REINFORCED❑MEMBRANE O S3 FLOOR FRAME/INSUL S4 MASONRY Si FIREPLACE S11 ROOF FRAMING ROOF SHEATHING S5 FRAMINIOAf�� /0-tA3 - INSULAT SOUND ENERGY S7 • LATH EXTERIOR S8 LATH INTERIORiGYPBOARD S9 APPROVED/INSPR'S SIGNATURE DATE OF ISSUANCE PERMIT NUMBER BUILDING FINAL S12