2367 Mall Ave.
CONTRACTOR INFORMATION:
STATELlNE CONTRACTING, INC
3013 W BALL RD
ANAHEIM, CA 92804 0000
BUSINESS PHONE: 714680.7766
JOB DESCRIPTION:Tear off existing roof and replace with 19 squares of 30 year composition shingles.
VALUATION: 4,000.00 PROCESSED BY: MSM
I OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's License 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 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 Business and 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 pena~y 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 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-builder will have the burden of proving that he
did not build or improve for the purpose of sale).
D I, as the owner of the property, am exclusively contracting with licensed oontractors 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).
D I am exempt under Sec. , B & P.C. for this reason:
Date: Owner:
I WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
D I have and will maintain a certificate of consent to self-insure for worker's compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued.
\r71' I have and will maintain worker's compensation insurance, as requilBd by Section 3700 of
~ Labor Code, for the performance of the work for which this permit is issued. My worker's
Compensation insurance carrier and policy are:
Carrier: ACORD
BUILDING PERMIT NO. BLD2005-02473
TYPE OF PERMIT CITY
Reroof
DATE: 8/8/2005
JOB ADDRESS: 2367 W MALL AVE
LEGAL DESCRIPTION: N TR 2001 LOT 55
APPLICANT: CHARLES SM ITH
OWNER INFORMATION:
WALTER E HUNT
2367 W MALL AVE
ANAHEIM, CA 92804
ElM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
INSPECTION REQUEST LINE:
(714) 765 - 4626
CENSUS CODE: 555
QUARTER SECTION: 33
ARCHITECT/ENGINEER INFORMATION:
Policy Numbe, 03KR0027574
This section need not be completed if the pennlt is for one hundred dollars ($100) or less.
D I certify that in the performance of the work for which this permit is issued, J 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 J should become/subject to th orker's com nsation
provisions of Section 3700 of the L b Codel shall orth th comply with ose provisions.
I
Date: 8/8/2005 Applicant:
WARNING: FAILURE TO SECUR WO ER'S COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALLSUBJE T AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL
FINES U P TO ONE HUNDRED OUSAND DOLLARS ($100,000), IN ADDI110N TO THE
COST OF COMPENSATION, DA AGES AS PROVI DED FOR IN SECTION 3706 OF THE
LABOR CODE, INTEREST AND' ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
J hereby affirm under penalty of perjury that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec.3097.Civ.C):
Lender's Information:
'certify that I have read this appiication and state that the above information is correct. 1
agree to comply with alt city ordinances and state laws relating to building construction, and
hereby authorize epresentives of t .s city to nter upon the above mentioned property for
in action p s.
Date: 8/8/2005
Signature of Applicant or Agent
The ermit shall expire by limitation and become null and void if the building or
work has not passed fi 001 inspection 365 days from the date of permit issull'lCe. A
new permit is required to commence or continue work.
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penatty of perjury that I am
licensed under provi ions of chapter 9 (commencing
with Sectio n 000) f Divs. n 3 of t Bu si ess and
Professio
8/8/2005
Date:
Contractor
NUMBER
825186
TYPE
TYPE
TYPE
EXPIRATION DATE
9/30/2005
A
B
C10
Construcion Types:
V N, ,
Fire Sprinklered?
NO
Fees paid for Permit:
Total:
160.61
City of Anaheim
Building Division
INSPECTION RECORD
INSPECTION DATE INSPECTOR
Temporary Power Pole
Plumbing (DrainlWaste Pipe)
Electrical Ground Electrode/Ufer
SetbacklFormsfTrenches (Footings)
Do not install subfloor or pour floor slab until the
following applicable items have been signed:
Plumbing (Water Pipe/Sprinkler Valves)
Mechanical (Groundwork)
Electrical (Underground Conduit)
Pre-slab (Compaction/Membrane Reinf.)
Underpinning (Floor Joist/Girders)
Do not cover or conceal the work below until the
following applicable items have been signed:
1st Floor Shear
Firesprinkler (Rough)
2nd Floor Shear
Roof (Sheathing/Diaphragm/Frame) ~Il~~ '-><C. / '--
Masonry (Reinf./Bond Beam/Pre-Grout)
Rough Plumbing (Top Out)
Rough Mechanical
Rough Electrical (Dry Wall)
Rough Electrical
Framing (Only after Plbg., Ele., Mec. And Fire)
Insulation (SoundlEnergy)
Do not tape or plaster unlilthe 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
Engineering/Grading Final 765-5126
Fire Dept. Final 765-4040
Water Engineering 765.5268
Sub List/Business License 765-5194
Zoning 765.5139
Building Final (Last Inspection - Only w- )J.~ 1< .fVIl S'rf(
Aller Above Complete)
PARTIAL INSPECTIONS
Buildina Insoections
Mechanical Inspections
Plumbina Insoections
Electricallnsoections