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Permit No. 1059100712 • 'A p,di'r'ia�°o '4,'i • 6. ,r-inder L- 1R5;SAN.BERNARDINO COUNTY-EPWA/LAND GEMENT DEPT 6FICE OF BUILDING AND SAFETY PERMIT APPLICATION PERMIT NBR 105 91 00712 255A 01 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL DATE 04/12/91 I ISSUE DATE 04/12/91 I PG 1 OF 1 PARCEL NUMBER 1017-672-06-0000 PROPOSED USE: GAS/ELECT LINES/BACKFLOW/ELECT CURRENT USE: RESIDENCE WITH GARAGE TRACT 13507-2I BLK 000 1018 LOT I NSEC W35 I O( 0RNG 8W PRCL 0 P I PRCL ACTIVITY : L820 COMMUNITY PLAN 1 ZONE/LAND USE DISTRICTGENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS CH/PD,ILI,FR1 I M-H LOT DIMENSION C ONST TYPE APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER PBLDGS ON LOT 1 GROUP BREDAHL, JOHN 16494 PATINA CT ;PLANS RECD 0 LAND USE PLOT 0 (INDEX NBR 50-164 - CHINO HILLS CA 91709-0000 STD PLAN/ICBO FHA ,(714) 597 - 6227 ITEM CNT DESCRIPTION DETAIL TOTALS OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER 1 TO 600/200 AMP SERV 29.00 BREDAHL,,JOHN 22 FIXTURES 17.64 16494 PATINA CT ELEC SUB-TOTAL 46.64 CHINO HILLS CA 91709-0000 1 GAS PIPING OUTLETS 19.00 -(714) 597 - 6227 1 VACUUM BREAKERS 19.00 PLUM SUB-TOTAL 38.00 J08_SITE ADDRESS ISSUANCE FEE 29.00 16494 PATINA CT TOTAL AMOUNT 113.64 CHINO HILLS CA 91709-0000 CROSS STREET AGATE ROAD INSPECTN ACCESS CONTRACTOR NAME, ADDRESS LICENSE NUMBER 9IY._OF IND._SAFETY PERMIT:_ __ - _ MINIMUM SETBACK DISTANCES 33 FRNT SETBACK/PROP LINE 15 REAR SETBACK/PROP LINE 5'SIDE SETBACK/PROP LINE 5 SIDE SETBACK/PROP LINE MECHANICAL EQUIP NOT PERMITTED IN REQUIRED SIDE SETBACKS NO:f{STORIES I NOITDWELLING I NO. BEDROOMS I FLOOR UN EXT. HALLS I INT. WALLS I CEILING ROOF I HEATINGI FIREPLACES METAL MASRY PUATEC (P SELk WER R] MINODEPTHI S.F./1001 SIZEI NEM/REPAIR COMMENTS 04/12/91 PRE ALTER DONE BY DON BAKER. D.FLETES. AMT WAIVED .00 AMT PAID 113.64 PAYOR NAME: JOHN BREDAHL PAID 04/12/91 RECEIPT 1316 EMPL: FLETS, DEBORAH PAID BY : CHECK NBR : 1638 t� - i. , • _ _ - ICENSED CONTRACTORS DECLARATION a I HEREBY AFFIRM THAT I AM LICENSED UNDER T PROVISIONS OF CHAPTER 9 (COMMENCING WITH SEWN 7000) OF DIVISION 3 OF THE BUSINESS ANf o. PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT LICENSE CLASS LICENSE NUMBER CONTRACTOR DATF 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 ILLI,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED �/T 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 WITHH/A CONTRACTORIS) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW( ❑ I AM E PT U ER / //// B AND P C FOR THIS REASON J QWNE /�1 DATF / 7/--if/ t 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 FILED WITH THE COUNTY BUILDING INSPECTION DEPARTMENT APPLICANT DATF ADDITIONAL REVISION 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 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 TATE THAT THE ABOVE II FORMATION IS CORRECT, I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILD G CONST UCTI N, REBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSP ION P POSE /' 4/a/I% GNATURE OF APPLICANT OR AGE / �/ DATE / / 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 12-17588.469 Rev 4/90 Owner-Name fi&''h 1 Permit Numf /COS ?/0o) INSPECTION RECORD DATE I INSPECTOR I __I DATE I INSPECTOR Setback Rough Plumbing f, j/Nth4'5 (9 Temporary Power Shower Pan Test Foundation Reinforcing Steel Stucco Mesh or Exterior Siding Excavation and Forms Insulation F H A. Foundation Req. Sewer Slab Grade Interceptor Ground Plumbing Septic Tank Underslab Ducts Leach Line or Seep Pit Underslab Conduit Li*// d Water Service Fireplace Foundation Lath or Drywall Nailing Joists and Girders Gas Line Air Test •4.9/ 'R' Electrical Ground Final Energy Mid-Height Bond Beam Final Plumbing 8-Foot Bond Beam Final Heating/A C Final Bond Beam Final Construction Fireplace Bond Beam Final On Site Improvements Roof Sheathing Final Off Site Improvements Framing and Ventilation Final Dedication Roof Covering Final Zoning Rough Heating Final Electrical IS49-7Z Electrical Service and GroundFinal Gas0"2,--C$Q iS".•/491-57 Rough Electrical LI9 7 Developer Fees Paid WC (YIN) Ind Saf Wig) Certificate of Occupancy • SEPTIC TANK GALS SEEP PIT X LEACH LINF WIDE X LONG X DEPTH OF ROCK N. W E S Inspector's Signature and Initials 12.17589-469 Rev 3/88