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Permit No. 7222 'I Y - r City of Ciao Hills APPLICAON FOR BUILDING PER Community Development 2001 Grand Avenue Chino HNIa,CA 91709 Building Address: Proposed Use - St No. 16494 Street PATINA rnl.MRT ROOM ADDITION APN 101 7-g77-ng THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT Lot 1Q Block Tract 13507-2 ® Struct ❑ Plumb. Applicant NCFti fl Mwr,h IRI Flert El Gradina St No. 16494 Street PATINA gni►RT Type of Project ®New ❑Alter ®Addition City 1A1n ialf i c ZIP 91709 Phone gQ7_1964 ❑ Repair ❑Convert ❑ Demo ❑Occupancy Permit Owner . �ICGnf Project Location on Size JOHN M. SIMCI -_ Description I Property I in Sq Feet St No. 16494 StreetPATINA COLJDT Cityf-Hlf�((1 un I c ZIP 91709 Phone 597-3864 1 ROOM ADDITION (INTERIOR 1162 Engr/Arch Lic No. 2 I I St No. Street 3 I I City Zip Phone 4 I I Contractor Lic No. REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTION Sewer I Min Depth I S/F/100 I Size St No. Street City Zip Phone Cubic Yards Excavation Fill Over Excavation City Business License License No Expiration Date Licensed Contractor's 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 effect License Class License Number Date Contractor __. . ...... .. . .. .. _.._.. _Address City and Zip Phone Owner Builder Declaration I hereby affirm that I am exempt from the Contractor's License Law for the following reason �. ❑ ._ I, as the owner of the property, or my employees with wages as their whole 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 am exempt under Sec____,B&PC for this reason Date '/6l k-f(- Initial • C- - Workers' Compensation Declaration I hereby affirm under penalty of perjury one of the following declarations Zoning ( Land Ike ❑a I have and will maintain a certificate of consent to self-insure for workers' PD FR1 compensation as provided by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued Setbacks I Model/Plan ❑ b I have and will maintain worker's compensation, as required by Section 3700 of the Pt' N/A I SY LaborCode, for the performance of the work for which this permit is issued My workers Ry I SSY compensation insurance carrier and policy number are Ins. Co.: Group/Division/Type Policy No: R-3 V-N Exp Date: VALUATION (T s dection need not be completed if the permit is for one hundred doolars($100) or less) $8,796.00 I certify that in the performance of the work for which this permit is issued I shall of employ any person in any manner so as to become subject to the Workers' Compensation PERMIT FEES Laws of California and agree that if I should become subject to th workers' compensation provisions of Section 3700 of the Labor Code I shall fort th comply with those Electrical Structural provisions p G $17.82 $129.60 Data I�v�V� 7� Signatuy� _ Warning Failure to secure workers' compensation coverage is unlawful, and shalt subject an Plumbing Grading employer to cnminal penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code interest and attorney's fees Mechanical Issuance $2900 I certify that I have read this application and state that the above information is correct I agree to comply with all City Ordinances Geo Review Plan Check and state laws and her-.• authonze representatives of this City Issuance Approved I Total Permit Fee to enter upon the abo - mentioned property for inspection rt," t17A 47 purpos ..' •--4--- -- (c— 1 y` -, Date Issued Permit Number Si atur ofjtfplicant or Agent Date I o 1..14 M. St NkO N S.14 10/8/96 7222 FINANCE CODE CENSUS CODE Print Applicant's/Agent's Name C-4 (CONSTRUCTION LENDING AGENC• 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) LENDER'S NAME LENDER'S ADDRESF 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. ❑ 1 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 38 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 APPLIEDFOR ON THIS PERMIT DIS ❑IS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY BUILDING INSPECTIONS RECORD DATE INSPECTOR I DATE INSPECTOR Setback/Location Rough Plumbing I Temporary Power Shower Pan Test Foundation Reinforcing Steel f ' Stucco Mesh or Exterior Siding , Excavation and Forms Insulation f//Z / /120 Slab Grade Sewer Ground Plumbing Soil Interceptor Ground Plumbing Water Septic Tank Underslab Ducts Leach Line or Seep Pit Underslab Conduit Water Service Underslab Gas Lath or Drywall Nailing /// 7/1%. Fireplace Foundation Gas Line Air Test Joists and Girders Final Energy Electrical Ground Final Plumbing Mid-Height Bond Beam Final Heating/A C 8-Foot Bond Beam Final Construction Final Bond Beam Final On Site Improvements Fireplace Bond Beam Final Off Site Improvements R heathing Final Dedication _ I n rami d Ventilation ///Ztij 1�( .J(� Final Zoning 141 VA' \ Roof Covering Final Electrical /' /\ I!r I J J IVY Rough Heating Final Gas h 71Z 1 vl W A Service and Ground ` .� Developer Fees Paid V1 VI r Rough Electrical ///(�/'f� /)7) Fire Dept Approval Verified /In • Bonding Certificate of Occupancy 1 r i Over Head Electrical Fence Height Gates Heater Pool Drainage SEPTIC TANK GALS SEEP PIT X LEACH LINE WIDE LONG X DEPTH OF ROCK N S Inspector's Signature and Initials DATE OF ISSUANCE PERMIT NUMBER