323 S. Shields
TYPE OF PERMIT CITY
Reroof
ElM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
INSPECTION REQUEST LINE:
(714) 765 - 4626
CENSUS CODE: 555
QUARTER SECTION: 20
BUILDING PERMIT NO. BLD2005-02997
DATE: 9/19/2005
JOB ADDRESS: 323 S SHIELDS DR
LEGAL DESCRIPTION: N TR 2755 LOT 5
APPLICANT: DICK VAN HAMERSVELD
OWNER INFORMATION: CONTRACTOR INFORMATION: ARCHITECT/ENGINEER INFORMATION:
JOHN W LOLKUS DICK VAN HAMERSVELD ROOFING CO
323 S SHIELDS DR 19712 MEADOWS CIR
ANAHEIM, CA 92804 CERRITOS, CA 907030000
BUSINESS PHONE: 562924-5308
JOB DESCRIPTION:Tear off existing and reroof 26 squares with 50-year composition shingles
VALUATION:
7,300.00
PROCESSED BY: JNJ
OWNER-BUILDER DECLARATION
I hereby a irm under penalty of perjury that I am exempt from the Contractor's Ucense Law for the fo! wing reason ( 00.7031.5 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 is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9)(commencing with Section 7000 of Division 3 of the Businessand Professions Code) or that he 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
($500).
D I, as owner of property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for
sale (sec. 7044 Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himself or helSelf 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 with one year of completion, the owner~builder will have the burden of proving that he
did not bu~d or improve tor the purpose of sale).
o I, as the owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions
Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with
a contractor(s) licensed pursuant to the Contractor's License Law).
o I am exempt under Sec. , B & P.C. for this reason:
Date: Owner:
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
o J have and will maintain a certificate of consentto self~insureforworker'scompensation,
as provided for by Section 3700 of the Labor Code, for the performance of the Work for which
this permit is issued.
E>t-l have and will maintain worker's compensation insurance, as required by Section 3700 of
The Labor Code, for the performance of the work for which this permit is issued. My worker's
Compensation insurance carrier and policy are:
Carrier: STATE FUND Policy Number. 285-0000731
This section need nol be completed if the pennit is lor one hundred dollars ($100) or less.
o J 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 worker's compensation laws
of Califomia, and agree that if I should bee e bj cl: the worker's compensation
provisions of Section 3700 of the Labor C ,sh with c m y with those provisions.
Date: 9/19/2005 Appllcantr':::"
WARNING: FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL
FINES UP TO ONE HUNDRED "!HOUSAND DOLLARS ($100,000), IN ADDI1l0N TO THE
COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE
LABOR CODE, INTEREST AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agell(';yfor the
per10rmance of the work for which this permit is issued (Sec. 3097.Civ.C):
Lender's Information:
9/19/2005
Date:
Contractor
NUMBER
383051
TYPE C39
EXPIRATION DATE
1013112007
Construc;on Tvpes:
VN, ,
read this application and state that the above in1ormation is correct I
ith all ity ordi n es and state laws relating to building construction, and
ntive of is city to enter upon the above mentioned property for
Date: 9/19/2005
Fees paid for Permit:
Total;
246.10
Ignature 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 permit issuMCe. A
new permit is reQuired to commence or continue work.
City of Anaheim
Building Division
INSPECTION RECORD
INSPECTION OATE INSPECTOR
Temporary Power Pole
Plumbing (DrainlWaste Pipe)
Electrical Ground ElectrodefUfer
SetbackfFormsfTrenches (Footings)
Do not Install subfloor or pour floor slab until the
following applicable items have been signed:
Plumbing (Water PipefSprinkler Valves)
Mechanical (Groundwork)
Electrical (Underground Conduit)
Pre-slab (CompactionfMembrane Reinf.)
Underpinning (Floor Joist/Girders)
Do not cover or conceal the work below until the
following applicable items have been signed:
1 st Floor Shear
Firesprinkler (Rough)
2nd Floor Shear /
Roof (SheathingfDiaphragmfFrame) f'11~b
Masonry (Reinf.fBond BeamfPre-Grout)
Rough Plumbing (Top Out)
Rough Mechanical
Rough Electrical (Dry Wall)
Rough Electrical
Framing (Only after Plbg., E:le., Mac. And Fire)
Insulation (Sound/Energy)
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 Coat)
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
EngineeringfGrading Final 765-5126
Fire Dept. Final 765-4040
Water Engineering 765.5268
Sub List/Business License 765-5194
Zoning 765-5139 .
BUilding Final (Lasllnspection - Only J .t \~ ./
After Above Complete) /~Jr ./7..,,;::>
~4
PLI
PARTIAL INSPECTIONS
Buildint;l Inspections
Mechanical Inspections
Plumbing Inspections
Electrical Inspections