4419 E. Pepper Creek Way
BUILDING PERMIT NO. BlD2005-00383
TYPEOFPERMIT CITY
Reroof
DATE: 2/11/2005
JOB ADDRESS: 4419 E PEPPER CREEK WAY
LEGAL DESCRIPTION: N TR 8418 LOT 44
APPLICANT: DANIEL SHIRLEY
OWNER INFORMATION:
:Trang Vu '
4419'E Pepper Creek Way
Anaheim, CA 92807
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714)765.5153
INSPECTION REQUEST liNE:
(714) 765.4626
CENSUS CODE: 555
QUARTER SECTION: 169
ARCHITECT/ENGINEER INFORMATION:
VALUATION: 14,000.00 i ,
!OWNER-BUILDER,'ECLARATION
I hereby affirm under penalty of perjury that I am exempt from the ContraCt-ti:::;',Lk.\~r.se Law for the following reason (Sec. 7031.5 Business and
Professions Code: any ciwor c~unlywhich requires a permit tq construct, aa>;.h,'~impiov~, demolish or repair anystructure"prior to its issuance. also
require.s the applicant for such permit to file a sign.edstatement that toe:5 lice\;sed plll'SUant to the provi-sions of the Contractor's License LaW'(Chapter
9)(commencing" with Section 7000 O,f Division 3 of the Business and ProfessirFH;: Code) or th~t he is exempt therefrom and the basis forthe aj!sged
exemption. Any violation of Section 7Q31.'5 by any C?pplicant for <:l permit sut.::~::::ts the a pplicar:t' to ,,a civii penattyof not more than five hundred dollars
($500),
o 1 as ownet of property, or my employees with wages as their sole cornp;~n5?tion, Wi!! clo the work, and the structure is not intended or offered for
sale (Sec. 7Q44'Business a"d Profes"s.ions Code: The Contractor'~ LicE:r.se L;'iW does not apply to en owner of property who builds or improves .
thereor:t, and who does SUt.t! work himself or herself or thr,6ugh his or her ow~;'empioyees, provided thC'lt such improvements are not intended or
offered fer: sale. If, however, the building or improvement is'sold with one ye~:;"" of rompletion, the owner-build~r will have the burden of proving that he
didnotbuildorimprovp-,forth~purposeofsale). . ';,: .,'. . ".
o I, as, the owner Cift:'e property, am exdusively contracting with licensed }'ontractcrs to construct the project (See. 7044 Business and Professio=1s
Cade: The'Contractor'~ License Law doe-.$ not apply to an.o.....mer of prope:!:y.'f.;ho bu:ids or iinproves thereon, and who contracts for suci1.proj,ect~ with
~ontractor(s) licens~ pursuant to the Contractor's License Law), ! .
LJ 'j am f\xempt under Sec. " -,.' ,B & P.C. for thi~ reason: )
Date: Owner: -r---
! WORKER'S COMPENSATION DECLARATION
I nei'ebyaffirm under penalty of perjury one.of the following declalaticns: _
o I have and will maintain a certificate of consent to se!f-:nsure for'..'.'o:'"ker'~ compElnsation,
as provi9"ed fer by Section 3700 of the Labor Code, for the' performanro cffr'}J work for whid1
~mit is issued. . . .
.. ave and will maintain.worker's,compensation insurance, as required ~I SeGtlon 3700.of
t e Labor Code, for the performance oithe work for which thfs permit. is isslJt.:d, Myworker's
Compensation insurance carrier and policy are: .
Carrier: STATE COMPENSATION FUND Policy Number. 1770283,2004
CONTRACTOR INFORMAflQN:
ORANGE COUNTY ROOF MART INC
,
171 GEMINI AVE ,
BREA, CA 92621 0000 f
BUSINESS PHONE: 714875-1588'
.JOB DESCRIPTION:, Tear off existing and reroof 40 squares with STWT Eagl) Penderosa tite @ 10 LBiSF
PROCESSED BY: JNJ
l
-=:J
LICENSED CONTRACTORS OECLARATIOI'!.J
I, hereby affirm under penalty of perjury that J am
iicensed It"r1der provisions ofchapter9{ccmmenClng
with,Section 7000) of Divsion 3 of the Business and
Profession~ ode.
2/11/2005
Date:
This section need not be completed if the pennit is for one hundred dollars ($10ci or'.l~s,
D I certify that in the performa!1ce of the work for which this pE::!rniit is iSSiJ€,d, fs"all not
employ any person in any manner so as to become subject to the worker's 'cf)mpensation laws
of.Califomia, and agree that if! should become subject to the worker's comj..:;.~>nsation
provis'ions of SeGUon 3700 of the labor Code, I shall forthw. h comply with tr';ose provis:ons.
~. .
Date: 2/11/2005. Applicant:' ,
WARNING: FAtLURETO SEC, EWORKER'S COMPENSATION COVEF.:~Gi:: S
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TQCRIMINAL PENN.TIES AND CIViL
FINES UPTOONE HUNDRED THOUSAND DOLLARS ($100,000), INA[)[)I1JbN TO THE
COST OF COMPENSATION, DAMAGES AS PROVIDED FOR. IN SECTION 3706 OF THE'
LABOR CODE, INTEREST AND ATTORNEY'S FEES. .
,. . '.. CQNSTRUCTION LENDING AGENCY , "
~ her?tl,yaffirm, '.mder r~n31~J.Qfrer!ur'lJhsttherE!. ic ;;CG!1~t!"~r:t!~n _~0.i1G.Ag.2.~_~Y:!,,:,),' tr.~
performance of the 'work fur which this' permit is issue'd (See. 3097 .Civ,C):
.Lender's Information:
NUMBER
818684
TYPE
Construcion Types:
VN, ,
I certify that I have r~ad this application arid state that the above in,formatibn is correct. I
agree to comply with all city ordinances and state laws relating to bu ilding construction, and
hereby-authorize representives of this city to enter upon the above mentioned property for
inspection p~s.
CbJ.,. Date: 2/11/2005
Signature of Applicant 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 from the date of perrrJt issuance.. A
new permit is required to commence or continue work.
C39
EXPIRATION DATE
6/30/2005
"'C:i;
Fees paid for Permit:
Total:
. 615.99
INSPECTION 'RECORD
INSPECTION. . DATE INSPECTOR
Temporary Power Pole
Plumbing (Dl'alnlWaste Pipe)
.. Electrical Ground Electrode/lifer .
SetbacklFormslTrenches (Footil!gs)
Do not install subfloor or pour floor slab untilthe
following applicable items have been signed:
Plumbing (Water Pipe.Sprinkler Valves)
Mechanical (GrOUndwork) .
Electrical (Undel'ground Conduit) .
Pre-:slab (CompactionlMembrane.Reinf. .
Underpinning (FlOOr Joist/Giiders)
Do not cover or conceal the work below until the
following applicable items have been signed: . .
.1st Floor Shear . ' . .
Firesprinkfer (Rough).
2nd Floor SlIear
Rool1Sheath.i&!DiaphragmlFrame) ~l/D(' .
Masonry (ReinfJBond BeamlPre-Grout) . . .
Rough Plumbing (Top Out) . ,
Rough Mechanical
KOugn ~ectric31 ( II) .
Rough Electrical . -- , .
Framing (Only after PlbQ.., EJec.. Mech.. and Fire) .
Insulation (SoundlEnergy) ,/
. Do not tape or plaster until the following applicable
items have been signed: ' " " .
Drywall . .
Penetrations (Fire Rated) Electrical .
Penetrations (Fire Rated) Mechanical
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 Date Inspector '
Electrical Final
Plumbing Final
Mechanical Final . ..
.
Gas Test .
.
Engineering/Grading Final 765-5126. . . .'
Fire Dept. Final 765-4040 .
Water Engineering 765-5268 .
Sub List/Business License 165-519
, Zoning 765-5139 . ............
Building Final . ~ast Inspection- Only ~.\s.os ~~
. fter Above Complete)
~\~s. <.
Mechanicallnsoections
,
Plumbincrlnsoections
Electricallnsoections