1622 W. Mells Ln.
;"
BUILDING,PERMIT NO. 'BLD2003~4396
~~O~~FPERMIT CITY
DATE: 11/12/2003
JOB ADDRESS: ' ,1622 W MELLS LN
LEGAL DESCRIPTION: N TR 3446 LOT 11
ElM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765~5153
INSPECTION REQUEST LINE:
(714) 765 - 4626
CENSUS CODE: 434
QUARTER SECTION: 57
APPLICANT: VICTOR CHYLlNSKI
OWNER INFORMATION:
Victor A Chylinskt
1622 W Mells Ln
Anaheim, CA 92802,
JOB DESCRIPTION,ear off existing shake and inslall 25 squares of 40 year:Oomp.
, VALUATION: 3,750.00
I OWNER-BOILi>E~~ DECLARATION
I hereby affirm IJnder pena,~ of perjury that I am exempt from the,Contract<f~ License Law for: the following .reason (Sec. 7.031_:5 BLis.iness.and
Professiqns Gode:iuiy dty t?r co~ntywhic~'requ1res a permit to co,,!struct, aj.~r, improve.. demolish or repair any structure, prior to its issuance, 'also , .
requires the: applicant for ~uchpermit to file a signed statement thathe is lic~nsed pursuant to the provisions of the Contractor's license law (Chapter .
9)(cc>mmericing withSection 7000 of Division 3 of the Business and Profes:~16n$ Code) or that he is exempt therefrom and the basis for the alleged .
exemption. Any violation of SeCtion 7031.5 by any ap_plicant for a,p'ermit sut~ectS the a'pphcant td a dVil penalty of not morethan five hundred dollars
. ~?)~s oy!n~r of propertY;;~'or m;'eC(!p1~yees with 'wages as th~ir sole' com;L~ation, ,win do the'w~rk, and th~ st~ucture is not in~~ndedOr off~red for'
~e (Sec. 7.944 ~usiness,and Professions Cod~:.The Contractor's License:::.aVv' does not apply to an owner of property who. builds or improves .
thereoh, and who does such work himself or herself or through his or her.ov.n ernployees,_provided that such!improvementsare not intended or
offered for sale. If.. however, the_ building or improvement is sold wi'th one ytkr of colTlpletion, the owner-_builder will have the: burden of proving that he
'di~ .nqt build ot,imp,rove-for the purpOse o(sal_e). .. . { . _ ' .,' _ " . . . ,. .
D I, as the ovmer of the property,-arn _Elxdusively contradi~gwithlicenserJ;contractors to construct the project (See. 7044 Business'and Professions
'Code: The Con'tractor's License ~w do~ not apply to an owne~ of prope,h;"yho builds or improves thereon, and who contracts for such projects with,
ontrador(s)'licensecl,pursuant to the Contractor's'Ucense Law).: '.
m ~~ pt nder$ec.,d/-~ ,:B &-P.C. for this reason:
Dal~ ,"1" ~ (l Owner: ,,,.;;,
"
'WORKER'SCOM NSATION DECLARATION .r
I he'reby affirm under penalty 'of perjury one, of the following declarations: ;
. ' , - , ~
o , l.have,and will' maintain a certificate, of consent to self-insure for worke(~ compensation,
as provideclfor by Sedion 3700.ofthe labor Code, for the performance oftr.:? work for which .
this permit is issued. " , ,'_ , . " _ , i. ..,.
o I IJaveand will maintain worker's comp'ensation insurance, as .required ~~~{ Sec;;tion 3700 of 11/12/2003
. .the_ labor- Code, for'the performance of the work for which this permit is Iss:~'Jd. My worker's Date:
Compensation insuranCe carrier and policy are:
Carrier: Policy Number:
This section need not be completed If t1iil pennlt Is to( one hundred donars ($1 ~~) or less" ,
0:,1, ge.rtify}hat in the perfomiance ofthe work for-which this per".1.i.t..~:::i~U~:d, ISh8,I! not
employ any persoh inany,manner so.as to ~ec6me subject.to the '-('{orKer's c:)lnpe~.ation laws
of Califomia" and agree that if I~hould become subject.to the work~r's'com~x~nsatio~ .
provisions of Secli,on 3700 of the Labor C . ,I shtorthw.t orC( yV/ithti-pse'pr<1Visions.
Date: 1111212003 Applicant:, ,
WARNING: FAILURE TO SECU WORKER'S COMPENSATION COVEr,,\G~JS '
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER'l'O CRIM INAL PENA'.TIES,'AND CIVIL
FINES UPTOONE HUNDRED. THOUSAND DOLLARS ($100,000):iINAD~ TION"irO THE
COST'OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION)70l?gF THE
LABOR COD E, INTEREST AND ATTORNEY'S FEES.";",
I CONSTRUCTION LENDING AGENCY ".' _
. I hereby affirm under pen'alty of perjury-that.there is,a cOQ,s~ruction lendingai:-)ncyforthe
~erf9r1!l?J:H::i:~.QOh_e work for whichJhi~_permjtj_~'-ssued--<Sei:.3Q9Z:Civ.C):___,_ ~. .' ~" "-il .....-.;
Lender's Information: . .'
i
I
,
CONTRACTOR INFORMATION:
\
}
ARCHITECT/ENGINEER INFORMATION:
PROCESSED BY: AEM
I
"
LICENSED CONTRACTORS DECLARATION]
.1 hereby affirm under penalty cf perjury that I am
. licensed under provislonsof chapter 9 (commencing
with Section 7000) of Divsion 3 of the Business and
Professions Code.. .
Contractor
NUMBER
EXPIRATION DATE
TYPE'
.
Construcion Types:
VN, .
Fire Sprinkle red?
NO
..;;,....,~,
""
'''.,
I certify -that.1 have read this application and state'that the abov~ information:$ correct. I .
agree to oomp(ywith all city ordinances and state laws relating to buDding construction, ahd
.hereby author:~, resentives of tho dty to, enter upon, the above' mentionea ,property for
i.nspediOn pur.t/~ .... {;,.. . . D~te: 11/12/2003
. Signature,of App ica or Agent .
The permit shall expire by limitation and become null and void if the building or
work has not passed final inspection 365 days fr!llll the date ofperrrJt issuance. A
new permit is required to commence or continue work,
Fees paid for Permit:
Total:
124.85 '
INSPECTION RECORD
. DATE .
.INSPECTION . . INSPECTOR
TemporarY Power Pole I
Plumbing (D",inIWaste Pipe) . . I
Electrical Ground Electrode/Ufer . .
SetbacklFClfRlSfTrenches(Footiligs) - .
. Do not install subfloor or pour floor slab IInlil.lhe.
following applicable items have been signed:
Plumbing (Water Pipe.Sprlnkler Valves)
Mechanical (Groundwork) , .
Electrical (UndeigroundConduit) I .
Pre-slab (CompactionlMembrane.Reinf.
Underpinning (Floor Joist/Girders) . ,
Do not cover orconceallhe work 'below until the ,
folloWing applicable items have been signed: , .
1st Floor Sheaf ., , "
FlresprinkJer (Rough) , ,
2nd Floor Shear . J
Roof (Sheathing/Diaphragm/Frame) /1
Masonry (RelnfJBond BeamlPre-Grout)
Rough Plumbing (Top Out) "
Rough Mechanical, '
Rough 8ectncal(Dry Wall) .
Rough Electrical .
Framing (Only afterF.lbg., Elec.. Mech. "and"Fire)
Insulation (SoundlEl\ergy)
Do not tape or plaster until the following applicable .,
.items ,have" been signed: - . .' :.
Drywall ,
Penetrations (Fire Rated) Electrical .
Penetrations (Fire Rated) MechlUlil:a1 .
Penetrations (Fire Rated) Plumbing ,
Interior Lath , "
Exterior Lath' . .
.. GENERAL ITEMS
exterior Plaster (Brown Coal) , , ,
T -Bar Electrical " .
T -Bar Mechanical ' . ' , "
T-Bar Structural , .
Sewer " . , ,
Water Engineering Backflow "
Water Service
.
FINAL INSPECTIONS
Electrical Final
Plumbing Final
Mechanical Final
Gas Test
Engineering/Grading Final 765-512,6
Fire Dept. Final 7654040
Water Engineering 765~5268
Sub List/Business License 765-519
Zoning 765-5139
Building Final (Last Inspection- Only" _," -aD
, AfterAbove Complete) ~ .. (
PARTIAL INSPECTIONS
BliildinQ Inspections
Date
Inspector
Mechanical Inspections
PlumbinQlnspections
Electrical Inspections