428 S. Shields Dr.
BUILDING PERMIT NO.' BLD2004-03126
ElM
BUILDING DIVISJQN .
200 S, ANAHEIM BL\l.D.
(714) 765 -5153
. . INSPECTION REQUEST LINE:
(714) 765- 4626
CENSUS CODE:. .555
QUARTER SECTION: 20
TYPE OF PERMIT 'C IT"Y"
Reroof
DATE: 8/1312004
. JO,B ADDRESS: 428 S SHIELDS DR
LEGALDESCRIPTION: N TR 2864 LOT 30'
APPLICANT: LEW FERGUSON
OWNER iNFORMATION: CONTRACTOR INFORMMION: ARCHITECT/ENGINEER INFORMATION:
Charmai ne Wilde MCCORMACK ROOFING C'.)
428 S Shields Dr 4091 E LA PALMA AVE #T
Anaheim, CA 92804 ANAHEIM, CA 928070000
. '. BUSINESS PHONE: 714'630';5543
JOB DESCRIPTION:Tearoff and replace existing'shake roof with 24 squares 01'30 yr. composition shingles..
VALUATiON: 4,700,00 'PROCESSED BY: MSM
I . , " OWNER-BUILDER f)ECLARATION . 'I
I hereby ~ffilll1 un~er penalty of pe~ury that lam eX_empt from the Contractor's Lic}nse ,Law for the foUoWing, reason (Sec; 7031.5 Business and Professions
Code: any'otyor county which requires a ,permit to construct,. alter, impr,ove,deri1':liish or repair any structure, prior to its issuance, -also requires-the applicant
for ~uch permit to file 2 signed statement that he is licensed pursuant to the providons,Df the Contr~ctor's Lice_nse Law (Chapter9)(commencl:'lg with Section
. 7000'of Division 6 oHI'e'BLlsiness and Professions Code) or that he is exempt lhdferrom and the basis for the alleQed exemption_ Any Vioratio.t of Section
7031,5 by-any' applicant for a.perr~lit subjects the applicant to a civil penalty of noll,~ore than five hundred dollars ($500)," , -
. .' "'0'. '
"_' _ '.: f': , ' - " " . _' ,,' .
. 0 ,I~ as ownt';'lr ofpfQperty, or my employees witt't wages as'their sole COJ11p'S!p.~,r.,:j~n" wi!! do thework, and the str:.Jctureis rot intended or offered for sale .
(Sec. 7044 Bus'iness _and'pj-of~ssjQns Code: The Contractor's License Law'dves 1m!, apply,to an owner' of property who bLli!ds or improY"es th<;fcon, and who / ._
does such wOrk himself or herself or thr.0ugh his or ",ef own emPloyee;:,;'J:':ToVided ,,~at suchimproyenlents Cl:re not intended' or offered for sale_ If, however, .the
bu'ildingor improv~ment is sold with one year'of completion, the owner-bwlderwi!i,have the'burden of proving tliat he,did'not build or imprQve forthe'purpose
of sale).. .. '!: . .
01, as the owner ofth_e property', am exclusively contracti,ng with licensed coot;ctors to construct the project '(See, 7044 Business and ProfesSio(lS'Code:
. The Cdntractor's'License Law'does not applytq an owner of property who builds ,,+ }mproves thereon, and who ~ntracts)or such projectswith a contractor(s)
. ~ensed,pursuant.t~ the Contractor's Lh:;ens,eLaw). ,-' '
W J qm e?Cempt under See, ,. ' . ,..S"&:P,C.forthis reason: -"";':r".
Date: 'Owner-:
I WORKER'S COMPENSATION DECLARATION
I hereby affirm un,der penalty ,of perjury one of the-fOllowing deClarations: .~,
o r have and'WilI maintain a'certificate of consentto self-insure forworker'scor\;€'ns2tion, as
provided for ~ySection 3700 of the LaborCOde;,for theperfcmnanceoftheWcrk f~',:_r vvhir:ih this
.~' iUs issued: . " . ,(. .
. ,I ha,ve and WI. 'I.l.maintain.worker's-oompensation insurance, as required by s~c,ti.-cn 3700 ohhe
, r Code, for the performance of the work for which this permit is issued, . My wxker's
Compensation' insurance carrier and policy are: " . " , _.. ". .
Carrier: AMERICAN iNTERNATIONAL GROUP Policy Number. W-37572f';,
, .... . .' .. ! .
This section need not be completed iflhe ponrit is for one hundred dollars ($100)0, less.
. 0 I certifyth'at i_n th~ performance ~ the work' for lNhich this p~nnitis, issued,! ~~allnot employ,'
- an.y "person in any manner 5'0 as to become subject.to the worker's compensation::3Ws of.California,
ana agree thatif.-I should be'come subjecUo th-e rker's compensation provisions of Sedion 3700
of the LaborOOde, I shall forthwith comply wi '.ep~n:.,~'. ' ';',
. Date: 8/13/2004 Applican . K.. .(5'CJ2
WARNING: fAILURE TO SECURE ORKER'S COMPEN
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE $ A,.. 'CI)fIL :'iNES UP TO
, ONE HUNDRED, THOUSAND DOLLARS ($100,OOOl,IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROViDED FOR IN SECTION 3706' OF THE LABOR CODE,
INTEREST AND ATTORNEY'S FEES, .
I CONStRUCTION LENDING. A(3!=NCY .
_ 1 hf>reby~ffil'J1"l1JI1r!l"!r pel1~lty ()f~p.ri!lry t!-l~t ~hQrA,!S,:'! "'(\n~tn_J/:'1-l~n!.::o"'riind?!:!.f.>i!::':'..f0r the-,
performance of the work for which this penn-it IS 'issued (See.3097 .Cjv~C):
Lende~s Information:
_r
::=J
LICENSED- CONTRACTORS DECLARAtiON
.I hereby affirm under penaltyaf perjuN:that I am
licensed unde'r provJsJons of chapter 9 (colTlin~nang with
, Section. 7000) of DivSi n 3 of the in ss and
Frofessions Cod
."
NUMBE
643700
TYPE
: TYPE
C39
HIC
EXPIRATIO
6/30/2006.
Construcion Types:
VN, ,
Fire SprinkJered?
NO
----'-~--'~-
lce'rtify that I have read ttliS appncation a.nd state thatthe above'information-is correct. I agree to
compfy .with all city ordinances and statela'NS relating to bUilding construction, and hereby authorize
representives,of this ity to enter po'n the above .mentioned property ~Of irJspectionpurposes._
. Fees paid for Permit:
Total:
138.93
Dale: 8/13/2004
, ' ' _ . Signature of ppJi nt or ent
The permitshaJl expil"!l by Iimitat an become null arid void if the building or work has
not passed final inspection 365 days from the date of pennit issuance. A new permit is
: I"!lquir,edlo COll'lInence or continue work.
'.. INSPECTION RECORD . . FINAL INSPECTIONS. Date . Inspector
". . '. INSPECTOR Electrical Fina! .
INSPECTION . .' .. DATE
T em'porary Power Pole '. . . Plumbing Final '. '. . .
. .
Plumbing (DrainlWaste Pipe) . .', Mechanical. Final .' .
. .
Electrical Ground Electl'9delUfer .' . . .'
SetbacklForl11SlTrenches (Footings) Gas Test .' . ",
Do not installsubfloor or pour floor slab until the Engineering/Grading Final 76505126
following applicable items have b~en signed: .' . . .
Plumbing (Water Pipe.Sprinkler Valves) . Fire Dept. Final 765-4040 .' ....
Mechanical (Groundwork) '. . . . .. '..
Wat"r Engine"ring 765-5268 .'.
Electrical (Underground Conduit) .. .
. Sub List/Busi.ness License 765-519
Pill-slab (Compaction/Membrane.Reinf. .. '.' . . . .
I,Jnderpihning(Floor Joist/Girders) . Zoning 765-5139 . ./ . ~.."
. '. '.
Do not cover or conceal the work belOW until the. Building Final\l:ast Inspection- Only 12il(O ~
following applicabl.e itemS .have been signed: . . . '. fter Above Complete) .
1 $tFloor Shear . . '. pARTIAL INSPEOTIONS '-' .' .
Fir<>sprir\kler (Rough) . . /Suildina Inspections
.2nd' Floor Shear. .. . /) -1/7 .
Roof (Sheathing/DiaphragmlFr,",e) !: -:Jb.f.1CoJ -I/"?~ ' . .'. , . . .
Masonry (RlI!infJBQndJ3QamlPre-Grout) . . /~ " ". .
Rough Plumbing (Top Out) <---' .
. Rougtl Mechanical . . . . . .. .
Rough l:Iectrical (Dry WaD} . .' .
. . . .
Rough Electrical . . . .
. .
Framing' (On!y affer P!bg.:EJec.:. Mech.. and Fire) .
Insulation (SoundlEriergy) .. MechanicallnsPElctions
po not tape or pla~ter . until the following applic<!ble .
It~mst1ave bee,n Signed: .. '., , '. . . .' .' '.' '.
Drywall. . ..
. . . .
Penetrations (Fir<> Rated) Electrical . '. .'
Penetrations (Fire Rated) MeChanical . . . . '.'
Penetrations'(Fire Rated) PlumbIng ..... '.
. . .
Inlerior Lath . . . '. .
Plumbina Inspections . .
Exterior Lath . , .' I . .
..' . GENERAL ITEMS . . ..' ..
Exterior Piaster (Brown Coat) . . ,
T-BarElectrical ..... . .' '. . . . '. .
.
T -Bar Me.chanical. . . .' . .
. . . ..
T -Bar Structural .
Sewer . .
.' . .
Water Engineering Backflow . . ElectricallnSDections
Water Service . > .
.'