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Permit No. 0180 -N. APPLITIN FOR GRADING AND OTHER MISCELLANEO ERMITS — CITY OF CHINO HILLS - APNi301 — 17 BUILDING qI �7� CLEARED BY APPLICATION TYPE NO C ADDRESSIn � ae( pr. �����IIS q F 0L. SLOT � BLOCK � � �� �� TRACT 1 3 Z -� , c) /+ � D OWNER Kam,y TO D I THE FOLLOWING WORK IS AUTHORIZED BY THIS PERMIT p ADDRESS �J 1 3061 i CO-0 fc-419-6( Pr- I g-SrRUCT O PLUMB 0.MECH 7 ELECT .GRADING M C/ CITY V1 f no H ills ZIP 91 70-1 PH 7f4- — 6Z7- --71 J 0 ,']NEW 0 ALTER II ADDITION i.SUPERVISEDrS)SIT GRADING ARCHITECT/ LIC NO _ REQUIRED ENGINEER ADDRESS 0 REPAIR O CONVERT ❑DEMO _`J CUBIC YDS CITY ZIP PH DISCRIPTION11OF WORK AND CONDITIONS OF APPROVAL CONTRACTOR LIC NO -2 Z l jZ! -e (n'1 ie I /• nA t � /t - ADDRESS I CITY ZIP PH I CITY BUSINESS UCENSEI LICENSE NO EXPIRATION DATF LICENSED CONTRACTOR S DECLARATION V' I hereby affirm that I am licensed under 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 Ucense Cl=« License Number Dat. Contractor ADDRESS CITY AND ZIP . PHONF - 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 1097,Civ C)Lender s Name' Lender's Address n CANNER-BUILDER DECLARATION / Ihby affirm that I am exempt from the Contractor's License Law for the following reason r I,as owner of the property,or my employees with wages as their sole compensation,will do the h� work,and the structure is not intended or offered for sale CL= ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the prolc , o/v 0 I am exempt under Sec p [ Z B&PC for this reason P Date 7v' INITIAl CJ - a WORKERS'COMPENSATION DECLARATION ' .„.i f VII 1^P•A I%` I hereby affirm that I have a certificate of consent to self insure,or a certificate of Workers' ' a 1.""'"""' —''" 1nGV 12 Compensation Insurance or a certified copy thereof POUCY NO COMPANY DATE EXPIRES ' Ni.„. .. I 0 Certified copy is hereby furnished CITY VERIFIED I �„ \�-”` lnitta�... `\� ❑Certified copy is filed with the city tV Dale APPLICANT v ,.,,,, CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE 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 VALUATION Date O 1Z APPLICANT PERMIT FEES 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 ELECTRICAL STRUCTURAL �-r v provision or this permit shall be deemed revoked PLUMBING I GRADING /// 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 MECHANICAL ISSUANCE FEES // HEREBY AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE GEO REVIEW I PLAN CHECK MENTION D PROPERTY FOR INSPECTION PURPOSESy J 45>-4 [ ArL ISSUANCE APPROVED TOTAL PERMIT FEE \ Signature of Applicant or Agent Date Q ''' -{ we 760 DATE OF ISSUA 4. /4 I PERMIT SR- Pnnt Applicant s/Agent's Name /)l/ (/ 1/�V