116 S. State College Blvd.
VALUATION: 40,000.00
I OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am 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 such permit to fife 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 exe'mpt 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 compenr,ation, 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 contractors to construct the project (Sec. 7044 Business and Professions
Code: The Contractor's License Law does not apply to an owner of propertywt,o 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:
o I have and will maintain a certificate of consent to setf-insureforworker'sc9mpensation,
as provided for by Section 3700 of the Labor Code, for the performance of the ","ork for which
this permit is issued.
D I have and will maintain worker's compensation insurance, as required by Section 3700 of
the Labor Code, for the performance of the war 'or which this permit is issued. Myworker's
Compensation insurance carrier and policy ar
Carrier: STATE FUND
BUILDING PERMIT NO, BLD2005-02131
TYPE OF PERMIT C
Tenant Improvement (Limited) ITY
DATE: 12/2/2005
JOB ADDRESS: 116 S STATE COLLEGE BLVD
LEGAL DESCRIPTiON: TR 1843 LOT 13 POR OF LOT -INC
APPLICANT: JIM MAXHAM
OWNER INFORMATION:
MARY L HAUCK
1776 HENDRIX AVE NOTRE DAME CT
THOUSAND OAKS, CA 913600000
CONTRACTOR INFORMATION:
J & C CONSTRUCTION SERVICES
1938 N BATAVIA #F
ORANGE, CA 92865 0000
BUSINESS PHONE: 714921-0500
JOB DESCRIPTIONJenant improvement, 1531sf Pizza Hut into Wingstreet.
ElM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
INSPECTION REQUEST LINE:
(714) 765 - 4626
CENSUS CODE: 437
QUARTER SECTION: 112
ARCHITECT/ENGINEER INFORMATION:
JOHN A CHIPMAN
50 S LAKE AVE
PASADENA, CA 91101 0000
PROCESSED BY: MSM
Policy Number. 1818399-05
This section need not be completed If th pennit is for one hundred dollars ($100) or less.
D I certify that in the perfonnance 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 worke~s compensation laws
of California, and agr.ee that if I should become subject to the worker's compensation
provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
Date: 12/812005 Applicant
WARNING: FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL
FINES UPTO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDlllON 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 agency for the
performance of the work for which this permit is issued (8ec.3097 .Civ .C):
Lender's Information:
I certify that I have read this application and state that the above information is correct. I
agree to comply with all city ordinances and state laws relating to building construction, and
hereby authorize representives of this city to enter upon the above mentioned property for
inspection purposes.
Date: 12/812005
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 permit issuance, A
new Dermit is reauired to commence or continue work.
LICENSED CONTRACTORS DECLARATION I
I hereby affirm under penalty of perjury that I am
licensed under provisions of chapter 9 (commencing
with Section 7000) of Divsion 3 of the Business and
Professions Code.
12/8/2005
Date:
Contractor
NUMBER
698215
TYPE
TYPE
EXPIRATION DATE
11130/2006
B
C33 PAIN
Construcion Types:
VN, ,
Occupancy Groups:
S, , , ,
Fire Sprinklered?
T.LArea:
NO
1,531
Fees paid for Permit:
Total:
1.137.05
City of Anaheim
Building Division
INSPECTION RECORD
INSPECTION DATE
Tempora Power Pole
Plumbin DrainlWaste Pipe
Electrical Ground Electrode/Ufer
SetbacklFormslTrenches Footin s
Do not install subfloor or pour floor slab until the
following applicable items have been signed:
Plumbin ater Pipe/Sprinkler Valves
Mechanical Groundwork
Electrical (Under round 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
INSPECTOR
Firesprinkler (Rough)
2nd Floor Shear
Roof (Sheathing/Diaphragm/Frame)
Mason 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)
Drywall
Penetrations (Fire Rated) Electrical
Penetrations (Fire Rated) Mechanical
Penetrations (Fire Rated) Plumbing
Interior Lath
Exterior Lath
GENERAL ITEMS
Exterior Plaster
T -Bar Electrical
T -Bar Mechanical
T-Bar Structural
Sewer
Water Engineering Backflow
Water Service
FINAL INSPECTIONS DATE INS ECTOR
Electrical Final / U I.r--
Plumbing Final I.' IL~I 1- '" --
Mechanical Final !~;LI""; ./ ~/
Gas Test h71("ro.... r-~\~
Cross Connection Control (714)7654260 t
Engineering/Grading Final 765.5126
Fire Dept. Final 765-4040
Water Engineering 765.5268 \
Sub List/Business License 765.5194 I ~I..I "I
Zoning 765-5139 f1
Building Final (Last Inspection - Only ~~ i-h)(..l'I\....
After Above Complete) 1-'" -
PARTIAL INSPECTIONS
Buildina Inspections
Mechanical Inspections
if;E4tt4tf~~rA
Electrical Inspections