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Permit No. 1058900893 (2) 4111 10'SAN BERNARDINO COUNTY-EPWA/LAND AGEMENT DEPT OFFICE OF BUILDING AND SAFE=Y P E RMI T APPLICATION ►' PERMIT NBR 105 89 00893 230A 01 I STATUS: ACTIV THIS IS NOT A PERMIT UNTIL ISSUED APPL DATE 04/18/89 I ISSUE DATE 04/18/89 I PG 1 OF 1 PARCEL NUMBER 1023-601-23-0000 PROPOSED USE: RETAINING WALL CURRENT USE: RESIDENCE W/GARAGE 13249TRAC BLK T SEC • T I 0 0 1029 I SE07 102S RNG PRCL 00AP I PRCLOACTIVITY COMMUNITY PLANL820 ZONE/LAND USE DISTRICT GENERAL PLAN SUBDIVISION NAME SUBDIVISION PARCEL NO CHINO HILLS CH/PUD RES-2 -- LOT DIMENSION IRREGULAR CONST TYPE APPLICANT NAME, MAILING ADDRESS, AND PHONE NUMBER *SLOGS ON LOT 1 (GROUP BALANCE, ROMEO 13108 SAN RAFAEL DR *PLANS RECD 0 LAND USE PLOT 0 INDEX NBR 22-131 CHINO HILLS CA 91709-0000 STD PLAN/ICBO FHA N ( ) - TYPE I SQ. FT. FACTOR/P.S.F. I ADJSTED AREA/VALUATN OWNER NAME, MAILING ADDRESS, AND PHONE NUMBER BALANCE, ROMEO PORCH 87 .20 18.00 13108 SAN RAFAEL DR FENCE 315 .20 63.00 CHINO HILLS CA 91709-0000 ( ) - CALC VALU 3,645.00 I ADJUSTED AREA 81 JOB SITE ADDRESS ITEM CNT DESCRIPTION DETAIL TOTALS 13108 SAN RAFAEL DR RESIDENTIAL CONSTRU 53.93 CHINO HILLS CA 91709-0000 TOTAL AMOUNT 53.93 CROSS STREET CHINO AVE INSPECTN ACCESS COMPLETED CONTRACTOR NAME, ADDRESS LICENSE NUMBER DATEq--2 7-7 DIV. OF IND SAFETY PERMIT: MUNIMUM SETBACK DISTANCES 49 FRNT SETBACK/CENTRLINE SAN RAFAEL DRIVE R/W 50 16 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. DWELLING I NO. BEDROOMS I FLOOR UNITEXT. WALLS INT. WALLS I CEILING ROOF HEATING FIREPLACES METAL IMASRY WATER PUBLIC (PUBLIC SEWER I MEN 000EPTHl S'000100I SIZ000EI NEW/REPAIR COMMENTS PRE ALTER DONE BY TOM BERNARD. AMT WAIVED .00 AMT PAID 53.93 PAYOR NAME: ARMENTA, RICHARD PAID 04/18/89 RECEIPT • 2016 EMPL: FLETS, DEBORAH PAID BY : CHECK NBR : 271 ,!` OICENSED CONTRACTORS DECLARATIONS 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 7 -, 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 IS 500] I ❑ 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 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 F1''1!' H PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW) ❑ I AM E..1'T UNDER B AND P C FOR THIS REASON 7 / // (q' OWNER .1 /_ DATF 7 i' , �C.,'''' _\1 ' / '/ /i/ / 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 DATE CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS, ($1001 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 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 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE AT THE ABOVE INFORMATION IS CORRECT, I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING NSTRUCTION, AND HEREBY RIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE j_____ TY FOR SES /-- / e-(pf' SIGONATURE OF APPLICANT ROR AGENTSPEC�I. ---",/,47.-'------ PC_ DATE / / l/ v EXPIRATION AND REFUND NOTICE APPLICATIONS FOR WHICH NO PERMIT IS SUED WITHIN 180 DAYS FROM THE DATE OF APPLICATION SHALL EXPIRE PERMITS SHALL EXPIRE IF WORK DOES NOT COMMENCE WITHIN 180 DAYS OF ISS NCE 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 FRO 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 10/88 '�a I�nf N S g °U 3a.<nf�-d/ Owner N�Name -p �_ :Permit Number O INSPECTION RECORD DATE INSPECTOR I I DATE I INSPECTOR Setback Rough Plumbing Temporary Power Shower Pan Test Foundation Reinforcing Steel �" 9 Stucco Mesh or Exterior Siding Excavation and Forms Lf meas Insulation F H A Foundation Req. Sewer Slab Grade Interceptor Ground Plumbing Septic Tank Underslab Ducts Leach Line or Seep Pit Underslab Conduit Water Service Fireplace Foundation Lath or Drywall Nailing Joists and Girders Gas Line Air Test Electrical Ground Final Energy Mid-Height Bond Beam Final Plumbing 8-Foot Bond Beam I Final Heating/A C Final Bond Beam ���, --�, {l'wG' 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 Electrical Service and Ground Final Gas Rough Electrical Developer Fees Paid WC (Y/N) Ind Saf (YIN) Certificate of Occupancy Le—L SEPTIC TANK GALS SEEP PIT X LEACH LINF WIDE X LONG X DEPTH OF ROCK N W E r 4 s �/1/ - Inspector's Signature and Initials A/11/ - Rev 3/88