4497 E. Pepper Creek Way
BUILDiNG PERMIT NO. BLD200S-00S71
TYPE OF PERMIT CITY
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BUILDING DIVISION
200 S, ANAHEIM BLVD,
(714) 765 - 5153
INSPECTION REQUEST LINE:
,(714)765-4626
CENSUS CODE: 555
QUARTER SECTION: 169
DATE: 3/4/2005
JOB ADDRESS: 4497 E PEPPER CREEK WAY
LEGAL DE'SCRIPTION: N TR 8418 LOT 63
APPLICANT: LEW FERGUSON
OWNER INFORMATION: CONTRACTOR INFORrVlATION: ARCHITECT/ENGINEER INFORMATION:
Jordan Isailovic MCCORMACK ROOFINt1 CO
4497 E Pepper Creek Way 4091 E LA PALMA AVE #T ,-
Anaheim, CA 92807 ANAHEIM, CA 928070001'
, ' BUSINESS PHONE: 714 6;:;0-5543
JOB DESCRIPTION:Tear off existing roof and-replace with 20 squares of met;~I' shakes ICBO# 4361_
VALUATION: 6,000.00
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 Cod e.: -a ny city or county which req uires a perm it. to construct, a F:e r, impiOveJ demo tish or repa ir any structure, prio r to its !ssuance, also
. requires 'the applicant for sudl permit bfile a sig'ned statement that he islictinred pursuant to the provisions'of the Contractor's Lic~nseLaw (Cttapter
9)(co"mmen~ing with 8ection7000 of DiVision 3 of the!: Business and-Professl:,)ns 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 su~jects the applicant to a civil penalty of not mo're than five hundred dollalts
($500). . ... '. .',
D. I, as ,owner of properyy, or my employees with.wages as their sole com;:ensation, will do the work, and the structure IS not intended or offered for
sale (Sec. 7044 Business and Profe~sions Code: The Contractor's License law does not apply to an owner of property who builds or improves.
thereon, and who does sudrwork himself or herself or through his or her 0"'/) er11ployees, provided that such improvements ar~ not intended or '
. offered for sale. .If, however, the ,building or improvement is sold with one Yf:,'3r of completion, the nwner.builder wil~h~ve the burden of proving that he
did not buitdor improve for the purpose of sale). . " '. . .
o I, as the owner of the property, am exdusively contracting with licensed':contractors to cq/'"lstruct the project (Sec. 7044 Business and Professions
Code: The Contractor's Ucense Law does not apply to an owner of prope:1yi....ho builds or improves, thereon. and who con~racts for sudl projects with
~ontractor(s) licensed pu~suant to the Contractor's License Law). I '
. U .1 am exempt under See, . , B & P.C. for. this reason:
Date: Owner: .
I WORKER'S COMPENSATION DECLARATION ! LICENSED CONTRACTORS DECLARATION I
I hereby affirm under penalty of pe~ury one of the following declarations: ~ I hereby affirm under penalty of perjury that I am
o 1 have and Wi..!l maintain a certificate of ronsent to.self-insu.re forWOrker\.:..:omp<:;n~'ation, !I~€nsed under provisions of chapter 9 (commencing
as.provided for by Section 3700 of the Labor Code, for t.he perfarm~nce of.tr"r-';~ wCHk fer which With SectIOn 7000) of DIVSlOnZ3 of the BUSiness and
~hi 'permitJsissued, '. . . '.: 'I profeSSion~bde ~
. 'I have and will maintain wolter's compensation insurance, as required bi..- Section 3700 o( 3'4/2005 t.
e Labor C9de, for the performance of the work for which this pern~it is j~u9d. My~orker's Date: . Contractor
Compensation insurance carrier and policy are: .:':
Carrier: AMERICAN INTERNATIONAL GROUP Policy Number. WC070,1C,~10200001 NUMBER EXPIRATION DATE
6437QO 6/30/2006
TYPE C39
PROCESSED BY: MSM
I
This section need nQt be completed if "the pennit is for one hundred dollars .($100ic.r less.
o I c~rtify that in the performance o'fthe work for which this permitis issuetj, I shall not
employ any person inany manner so as to become subject to the worker's c"mpensation laws
of Califomia, and agree, ttJat if I should. become subject to the worker's ccmpj.-,.,saiion
,provisions of Section 3700 of the Labor Code h~1I fo~i1h comply With1'IV"e provisions,
'Date: 3/4/2005 Applicant: ;e::, '_,
WARNING: FAILURE TO SECUR WORKER'S COMPENSATI N OVERAGE IS
UNLAWFUL, AND SHALL SUBJE T AN EMPLOYER TO CRIMINAL PENALTIES AND CIVil
FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), iN ADDI1l0N TO THE
, COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE
LABOR CODE, INTEREST AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
. I hereby affirm under penalty of perjury that there is a construction lending ag\~ilcyfor the
performance of the work for which this permit" is issued (Sec.3097 .Civ .C): f
Lender's tnformation: J
,
C6nstrucion Types:
VN" ,
Fire Sorinklered?
NO
I certify that I have read' this application and state that the above informatlafl i~, correct.. I
agree to comply with all city ordinances an.d State laws relating to huilding COllstructiop, and
here author:ize representives of this city to enter upon the above mentioned property for
ins io ses.
Fees paid' for Permit:
Total:
160.71
~-e... Oate:3/4/2005
Signature.of AppliCant ent
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 issuance. A
, new permit is required to commence or continue work.
, INSPECTiON RECORD
I,NSPEC,TION DATE INSPECTOR
Tempotary Power Pole
Plumbing (DrainlWaste Pipe), ' , , ,,'
Electtical Ground Electrode/uter . ,
,SetbacklFormsfTrenches (Footings)
Do not i"l'tall subfloor or pour floor slab until the
fOllowing appliGable items have been signed:
Plumbing (Water Plpe.Sprinkler Valves)
Mechanical (Groundwotk)
Electrical (Underground Conduit) ,
Pre-slab (CompactiorvMernbrane.Ret nt. ' ,
Underpinning (Roor Joist/Girders) , ,
Do not cover or conceal the work below until the
following applicable items have been signed:, '
1 st Floor Shear
Flresprinkler (Rough) , ' " ' "
2nd Floor SIuoar , ~
Roof athillilfDlaohraam'Frame) '>I7/1\"r1 ' V~ { ",//,
Masonry (Reinf.JBond BeamlPre-Grout) I
Rough Plumbing (Top Out) ",
Rough Mechanical ' ,
. ,,",ugn l:Iec,trlC all) ,
Rough Electrical ,
Frain/ng' (ORly .her PJbg,. Elee: Mech..and Fire) ,
Insulation'(SouncllEnergy) ,
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 -B",r 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 7SS:S126
Fire Dept. Final 7~5-4040
Water Engineering 765~5268
Sub List/Business License7~5-519 ,
ZO,ning 765-5139 "
Building Final Itast Inspection. Only" f- 2S -Of ~o'
fler Above Complete) --.5l Ov.
PARTIAL INSPECTIONS I
Buildinalnsoections '
Mechanicallnsoections
Plumbina Insoections
Electricallnsoections,