110 W. Valencia Ave.
TYPE QF PERMIT
Blockwall / Columns C I TV
DATE: 4/22/2005
JOB ADDRESS: 110 W VALENCIA A liE
LEGAL DESCRIPTION: N TR 1194 LOT 18
ElM
BUILDING DIVISION
200 S. ANAHEIM BLVD. .
(714)765 - 5153
INSPECTION REQUEST liNE:
. (714) 765 - 4626
CENSUS CODE: .434
QUARTER SECTION: 85
BUILDING PERMIT NO. BLD2005-01160
APPLICANT: ANSELMO' CARRERA
OWNER INFORMATION:
Anselmo. Carrera
11,0 W Valencia Ave
Anaheim, CA 92805
JOB DESCRIPTION:Build 62 lineal feet of 6 foot high block wall per city specifications.
V ALUA TION: 2,000.00
I OWNER-BUILDER DECLARATION.
J hereby affirm under penalty of perlury that.1 a01' exempt from the Contractor's Ucense Law for the following reason (Sec. 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 slj"~h permit-to file a signed statement thathe i~ licerif?69 pursuant to the provisions of the Contractor's License: Law (Chapter:
9)(co'mmencing with Section 7000 of Division 3 of the Business and Profes~ion!:fCode) or that tie is exempt therefro!l) and the basis for tnealleged
exemption. Any viotation of Section-7031.5 by-any.applicant for a permit subjects the applicant to a civil penaftyof not more than five hundred dollars
!.O?)~ owner of property, .or. m., y employees With \Nage~ a. ".their so. Ie co~p. ~nsation,. ~iU .~o t/')e work, and the st.ructu...,e..is not in..tended or off ered for.
ae (Sec. 7044 Business.and .~Jofessions Code.: The Contractor's Licens~ ~w does not applyt.o an owner of p~operty who ,builds or.improves
hereon, and who does such wo'rk himself or herself 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-bu-i1derwill have ttie burde:m'of proving that he".:
did not build or improve for the purpose of sale). , ' _, " ' .
o I, as the owner of the property, am exclusively contl3cting 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 propertywho-builds or improvesthereon, and who contracts for such projec;::ts lfoIith
t=jontractor(s) licensed pur~uantto the Contractor's .License Law). .
l'f . e~empt under See; . ' & P.C for ~hi reason:
Date: ~D Owner:
. WORKER'S OMPENSATION DECLARATION
I hereby affirm under penalty of pe~ury one of the following declarations:
o I have and_ will maintain a certificate of consent to self-ins'urefor worker'sbom.pensation,
as provided for by Section 3700 of the Labor Code, for the performanCe of the'work for which
this pen;,it is issued.
o I have and will maintain worker's compensation insurance, as required by Section 3700 of
the Labor Code, for the perforr,nance of the work for which this permit ,is issued. Myworker's
Compensation insurance carrier and policy are: .
Carrier: . Policy Number.
ih' section need not be completed ifttie pennit is for one hundred dollars ($100) or less.
, I certify that in the perfon:n~nceof the work for which thi$ permit is iSsued, I shall not .
e ploy any person in any manner so as to become subjectto the worker's compensation laws
of Califomia, and agree that if I should become subject to ~he womer's comper;sation
provisions of Section 3700 of the Labor. Cod I sh<;ill forthwith comply with those provisions.
CONTRACTOR INFORMATION:
ARCHITECT/ENGINEER INFORMATION:
PROCESSED BY: MSM
.1
>;;,.
:r:
LICENSED CONTRACTORS DECLARATION
J hereby affirm under penalty of perjury that I am
licens'ed under prOvisions of chapter 9 (commenctng
with Section 7000) of Divsion 3 of tt)e Business-and
Professions. Code..
4/22/2005
Date:
, Contractor
NUMBER
EXPIRATIONDATE
TYPE
Date' 4/22/2005 ~ppllcant:
WARNING: FAILURE TO S.ECUR ORKER'S COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJE .AN EMpLOYER TO CRIMINAL PENALTIES AND CIVIL
FINES UP TO ON'E HUNDRED . OUSAND DOLLARS ($100,000), IN ADDIllON TO THE
COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 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 agency for the
p~rforrDance of the work for which this permit is issued (Sec:3097.Civ.C):
Lender's Information:
Construcion Types:
VN, ,
Fire Sprinklered?
NO
\ certi1y 1hat I have read this application and state that the above in10rmation is correct. I
agree to comply. with all city ordinances and state laws relating to building construction, and
her by authorize rep!'Ssentives of this city to enter upon the above mentioned property for
i 'ectio purposes. 'c
. ~ 0 r.Z/I!?L?lI1A Date: 4/22/2005
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 perniit issuMCe. . A
new permit is re.quired to commence or continue work. .
,Fees paid for Permit:
Total:
125.79
INSPECTION RECORD
" ,INSPECTION , , , DATE INSPECTOR
Temporary Power Pole ' ,
Plumbing (DrainlWaste Pipe)
Electrical Ground Electrode/Ufer " J ,
SelbacklFormsrrrenches(Footings ) Uhf 11/[ /7>
Do not install subfl~r or pour 1190r slab '!ntifth/) ,
following applicable Items have been Signed:, "
plumbil1!l (Water Plpe.Sprinkler Valves) , ,
Mechlinical (G~OUndwork) , ,', , ,
Electrical (Underground Conduit)
'., Pre-slab (C~action/Membrane.Reinf.
Underpinning (Floor Joist/Girders) ,
Do not cover or conceal the work below until the
following applicable ilems have been signed: "
1 st Floor Shear ' , , "
Firesprinkler (Rough) ,
" 2nd Floor Shear ' ,
Rllof(Sheathing/Oiat>hlagmlFranel .-... AA /
Masonry (ReinfJBond Bean/Pr.Grout) '/-"2-7 -<:'l ,ff /<--y
Rough Plumbing (Top Out) /j
Rough Me,chanical , //
Rllugn ~ectrlCaI ( II),
Rough Electrical
Framing (Only afterPlbg., Elec.. Mech.. -and Fire)
Insulation (SoundlEnergy) , ,
Do, not tape ,or plaster until the following applicable
items have been signed: .
Drywall , , ,
P!lf1etrallons (Fire Rated) Electrical ,',
Penetrations (Fire Rated) Mechanical , u
Penetrations (Fire Rated) Plumbing
Interior Lath ' , ,
Exterior Lath ,
c , GENERAL ITEMS
Exterior Plaster (Brown Coal) , ,
T -Bar ,Electrical -:-'
T .Bar Mechanical
T .BarStructural
,Sewer , ' '
Water Engineering Backflow I
Water Service
FINAL INSPECTIONS , Dale Inspector
Electrical Final' , ,', ','
Plumbing Final "
Mechanical Final ,
Gas Test -
" , " . ,
Engineeril19'Grading Final 765-5126
Fire Dept. Final 765-4040 , .
Water Engineering 165.5268' ' ,
Sub List/Business License 765.519 , ,
, "
Zoning 765-5139 , " .~" .J/{
Building Final lkast Inspection. Only If; 0 "', L.o;' ~1/^
, I fler Above Complete) ')t dS '- '-~~
PARTIAL INSPECTIONS,
,Buildina hlspections
, ,
Mechanical Inspections
Plumbina InsDections
ElectricallnSDections
ci '~ /; r H f.
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I, -eX.l.;'1 i<,u o",,."T "".:s
PLANNING DEPARTMENT NOT APPROVE VIOLATION OF ANY ~1'
..~...... ........." 6__ :r,,;, BUILDING CODES OF Tl'!~~C.I:;;: -..--.
~ l:i5~'/6st:U \' THE H AT'" HIS OWN RISK.
~ ^ ~c PROCEEDS
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