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Permit No. 4139 0 I fl CITY OF CHINO HILLS APPLICATION FOR A BUILDING PERMIT AND COMMUNITY DEVELOPMENT A CERTIFICATE OF USE & OCCUPANCY 2001 Grand Avenue IN __ Chino Hills, CA 91709 BUILDING �+ }��/ `/.� PROPOSED USE- co ADDRESS D�� 13 VI STA 11�-t- "V` ^ v W /� 1 �./� "2-WAu '[�f/YT/.T,' Pr 1 a APN ' () _“tie d-s Z 1 t THE LOWING WORK IS AUTHORIZED BY THIS PERMIT y S LOT I' sr BLOCK TRACT ./ - LW�TRUCT 0 PLUMB ❑ MECH ❑ ELECT ❑ GRADING 0 �/ 73 TYPE OF PERMIT ❑ NEW 0 ALTER 0 ADDITION m APPLICANT BkAs ' I 1 —r CO y� l�unn� 0 REPAIR 0 CONVERT 0 DEMO 0 OCCUPANCY PMT f0 ADDRESS ail,23I 1 pal �,//�-l� Ni. ROJECT I LOCATION ON I SIZE �(I�� i1lAv sw c"- �Jf �•�l DESCRIPTION PROPERTY IN SO FEET /V_l CITY / /.' tysru.A R4LS I dR ZIP c1-1 C'�1 PH J /`J-I O� i I I & r 0 0 1 J II OWNER tt\in6 AN Minot- 2 I I 1/4.1" ADDRESS 3 I I CITY ZIP PH �_ ARCH ENGINEER �B1.IA/t I}1a..� Y�C- LIC No 4REMARKS/SPECIAL CONDITIONS/PROJECT DESCRIPTIONA(X�_ ADDRESS y/O`) C�os NO STORIES NO DWELLING UNITS BEDROOMS ;* CITY r(l,(N�1" LP /)nom/(i PH -Q81� ROOF I FLOOR I EXT WALL I INT WALL �P CONTRACTOR Q, _ $ 91Q _/ d+X+ LIC NO ADDRESS V�A/��V� CEILING HEATING I FIREPLACE METAL MASONRY J/�' CITY ZIP PH SEWER MIN DEPTH S/F/100 I SIZE `1ml CITY BUSINESS LICENSE �•l LICENSE NO EXPIRATION DATE LICENSED CONTRACTOR'S DECLARATION CUBIC YARDS EXCAVATION FILL OVER EXCAVATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000 of Division 3 oft •Business and Professions Code,and my/l liic ce nse Is in full force and affect License Class y ' Lieems Number At/a IZ IA/(t.(- Dat• Date ^antractor d(9 I ADDRESS CITY AND ZIP PHONE OWNER BUILDING DECLARATION I hereby affirm that I am exempt from the Contractor a License Law for the following reason o I•a 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 lthasprolecl owner of Ne property,am exclusively contracting with licensed contractors to construct I e ZONING LAND USE 0 I am exempt under Sea B&PC for this reason I Date INITIAI SETBACKS I MODEL/PLAN WORKERS'COMPENSATION DECLARATION FY I SY I hereby affirm that I hays a certificate of consent to self insure,or a certificate of Workers' Compensation Insurance,or a certified copy thereof na RY I SSY I 772/24.4767.43 COMPANY �.N-5-NPOLICY NO sL"O90rYT7-Y GROUP DIVISION TYPE 0 Certified copy is hereby furnished DATE EXPIRES 0 Certified copy is filed with the city CITY VERIFIED VALUATION asp?— n )(AL ,/ �(pb Date 42 1 APPLICANT 1'` /L A'X rut t PERMIT FEES CERTIFICATE OF EXEMPTION FROM WORKERS dbMPENSATIDN INSURANCE I certify that in performance of the work for which this permit is issued,I shall not employ any ELECTRICAL I STRUCTURAL 0 / r Y irjbperson in any manner so a to become subject to the Workers Compensation Law of California , Dat- APPLICANT 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 Coda,you must lonhwith comply M with such provisions or this puma shall be deemed revoked MECHANICAL I ISSUANCE FEES 1 !CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMA- t TION IS CORRECT I AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS, GEO REVIEW I PLAN CHECK AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES 1 /jisr" ISSUANCE APPROVED I TOTAL PERMIT FE Signature of[�/pbcani or A� O Date rrsA ^ O! 1' DATE O 1 ANCE95 I PERMi]fyU b1 Print Applicant a/Agent's Name r (^�(\ `1' /�^//�j[—(A/ FINANCE CODE ^ l 1 • Operator: VIRGINIA Check I: 000000000 Date: 2/09/95 00 Receipt A: 0000345 WHITE- FILE/GREEN- FINANCE/YELLOW- OFFICE/PINK- OWNER CHECK $93.130 Tendered 5$93.90 GOLD-ASSESSOR/MANILA - INSPECTOR "'CONSTRUCTION LENDING AGEN• 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 ADDRFcc DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION - ' THE CALIFORNIA HEALTH AND SAFETYCODE REQUIRESA DIVISION OF INDUSTRIAL SAFETY PERMIT AS A PREREQUISITE TO PERMIT ISSUANCE UNLESS THE APPLICANT SIGNS ONE'OF THE'CERTIFICATES BELOW •{ i O I CERTIFY THAT NO EXCAVATIONS 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 O 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 I HAVE READ THE HAZARDOUS MATERIALS QUESTIONNAIRE AND THE WORK APPLIED FOR ON THIS PERMIT OIS OIS NOT SUBJECT TO THE r APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY { 1 ikc .f I• i I c- �• - r �1 ` 1 11 4I-4'tit w`rr+-,P .rj),•^ .H.A,T'.i •ONSTRUCTION LENDING AGEN• 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 'i ENDER'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 , D 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 DIS DIS NOT SUBJECT TO THE APPLICABLE REQUIREMENTS OF THE HEALTH AND SAFETY CODE AND THE LOCAL AIR QUALITY AGENCY BUILDING INSPECTIONS RECORD DATE INSPECTOR DATE INSPECTOR Setback/Location Rough Plumbing Temporary Power Shower Pan Test Foundation Reinforcing Steel //y- Stucco Mesh or Exterior Siding Excavation and Forms - Insulation Slab Grade Sewer Ground Plumbing Soil Interceptor Ground Plumbing Water Septic Tank Underslab Ducts Leach Line or Seep Pit Underslab Conduit I Water Service Underslab Gas Lath or Drywall Nailing 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 /j/1/F5 ,4vre' Final Bond Beam j/"Y/ Final On Site Improvements Fireplace Bond Beam Final Off Site Improvements Roof Sheathing Final Dedication Framing and Ventilation Final Zoning Roof Covering Final Electrical Rough Heating Final Gas Service and Ground Developer Fees Paid Rough Electrical Fire Dept Approval Verified Bonding Certificate of Occupancy Over Head Electrical Fence Height Gates Heater Pool Drainage SEPTIC TANK GALS SEEP PIT X LEACH LINE WIDE LONG X DEPTH OF ROCK i+ W E Inspector's Signature and Initials /(6 J DATE OF ISSUANCE PERMIT NUMBER