2883 W. Lincoln Ave.
VALUATION: 25,000.00
I OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor":i_Ucense Law for the"following reason (Sec. 7031.5 Business and
Professions Code: any city or county which "requires a permit. to construct, altl~r, impmve, demolish or repair any structure, prior to its issuance, also
requires' the. applicant for such permit to file a signed statement that he is tice'lped piJfSuant to the provisions of the Contractor's License Law (Chapter
9)(commencing with Section 7000 of Division 3d the Business and Professk::G~CodB) 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 sul:i:,&6ts the a ppliC811t to a civil pen'alty of not more than five. hundred dollars
($500), '. '. .:
o I, as owner of property, or my employees with wages as their, sole comp~65~t!On, will de the work, and t~estructure fsnot intended or offered for
sale (Sec. 7044 Business and Professions Code: The Contractor's Ucenset;:w 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 ow~,'emp!oyees, provided that such im;:>rovements are not in'tended or
affered far' sale-. ,If, however, the building or improvement is sold with cine ye::;';r of completion, the oWner-builder will have the burden of proving that he
did not build or improve for the purpese of sale). . " .
o I, as the-owner of the property, amexdusively co~racl:ing with licen.sed ~on!raci.ors.to construct the project (Sec. 7044 Business and Professions
Code: The Contractor's .License Law does not apply to an owner of property :"ho builGS or improves t!-lereon, and who contrac;ts for such projects w;1h
~ontractor(s) licensed pursuant to the Contractor's License law).
. U I am exempt under Sec. . , B & P.C. for this reaso:.:
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 (3 certificate of consent to self~insute for worker',; compensation,
as provided f.or by Section '''A70Q of the, Labor Code, for the perfonn~nce af t!1+iivcrkfor which
~this, rmitis is.sued. ... .; . .
." . I have and will maintain -worker's compensation insurance, aS'required b~.; SectiOn 3700 of
e Labor Code, for the performance oJ. the work for which this permit is issu~d. My worker's
Compensation il1surance <;:arlieI' and poliey are:
Carrier: _ Polley Number EXEMPT' .
BUILDING PERMIT NO, BLD2004-03529
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CITY Q<E~~N~HEIM
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TYPE OF PERMIT
Tenant Improvement (Limited)
DATE: 10/612004
JOB ADDRESS: 2883 W LINCOLN AVE
LEGAL DESCRIPTION: P BK 143 PG 31 PAR 1
APPLICANT: DONG S HYON
OWNER INFORMATION:
AlrEBel
1205 E Chapman Ave
Orange, CA 92866
CONTRACTOR INFORMPTION:
DONG S HYON
5392 PEMBURY DR
LA PALMA, CA 9C623000e
BUSINESS PHONE: 714991-2045
JOB DESCR1PTIONJenant improvement, exist. retail space into jucie bar
"
BUILDING DIVISION
200 S. ANAHEIM. BLVD.
(714) 765.51.53
INSPECTION REOUESTLlNE:
(714) 765 - 4626
.CENSUS CODE: 437
QUARTER SECTION: 12
ARCHITECT/ENGINEER INFORMATION:
PROCESSED BY: KBT
"I
This section need not be completed if the pennit is fot one hundred dollars ($1 DC; br less.
o I c.ertify that in the perfonnance of the work fo~ which this permit is issue,~ I-sha!l not
employ any person in any manner so as to become subject to the worker's ccrppensatlon laws
of Califomla, and agree 1hat if I shOUld becom'e subject to the worker's comp:::nsatton
provisions of Section 3700 of the Labor Code, I shall forthwith comply with t;'u~e proyisions.
Date: 10/612004 ' Applicant: ~ I
WARNING: FAILURE TO SECU EWORK COMPENSATIGNCOVER\GE IS
UNLAWFUL, AND SHALL SUBJECT AN E LOYER TO CRIMINAL PEN.A.'TIES AND CIVIL
FINES UPTO ONE HUNDRED THOUSAND DOLLARS ($100,000), -IN I>.DD'110N TO THE
COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTIO'" 1706 OF THE
LABOR CODE, INTEREST AND ATTORNEY'S FEES.
L CONSTRUCTION LENDING AGENCY .
-j ile(;;:::uY--dfii;,Yl una,;, jJe.ll~ity oj p.::rji.iry (haL titelc.::: ~ i:I DJll::>"udi0fl ic;~tii:-il:J O~":'Il\..Y 1<.., ~i-,e
performance of the work for which this permit IS issued (Sec.3097 .Civ.C):
Lender's Information:
I certify that I have read 1his application and state that the abov~ information is correct. I
agree to oomply with all city ordinances and ~ate laws relating to bu~ding construction, and
~ereb .authorize repre~~.s sat of t tnhis.city to enter upon the above mentioned property for
sp ctlon p poses. .~ . .
Date 10/6/2004
ature of Applicant or Agent
The permit s expire by limitation and become null and void if the building or
work. has not passed final inspection 365 days from the date of permit issuance. A
new permit is required to commence or continue work.
LICENSED CONTRACTORS DECLARATION
I hereby' affirm under penalty of perjury that I am
licensed under proviSions of chapter 9 (commencing
with Section-7000) of DivslQn 3 of the BusineSS and
Professio Co .e. I ~ .
101612004 ~.s-u
Date:
NUMBER
552553
TYPE
TYPE
TYPE
B
C10
C20 HT AC
Construcion Types:
VN, ,
Occupancy Groups:
B, , , ,
Fire Sprinkler"ed?
NO
Fees paid for Permit:
Total:
2,048.94
INSPECTION RECORD
, ,INSPECTION ' 'DATE: INSPECTOR "
Temporary Power POle
Plumbing (DrainM'a!lte Pipe) " , ,
Electrical Ground Electrode/Ufer "
SetbacklFormslTrenehes (Footings),
Do not install subfloor or pour floor slab until the
following appliCable items have bE$:en signed:
Plumbing (Water Pipe.Sprinkler Valves)
lIIlechallic,al (Groundwprk)
ElectricaljUnderground Conduit)
Pre-slab (Compaction/lIIlembrane.Rei nf.
Underpinning (Aoor Joist/Girders)
Do not cover or conceal the work below until,the
follOWing app'lic<,!ble items have been,signed:'
1 st Floor Shear " '
Fil&Sprinkler (Rough)' ' , " "
.
2no Floor Shear , ,
Roof (Sheathing/Diaphragm/Frame) ,
Masonry (ReinfJBOlld BeanIPre-GlO\It) ,
Rough Plumbing (Top Out) -
,
Rough Mechanical. , "
ROugh E1ectrlCalllJI'y waUl ,
Rough Elecirical ' " , , " ,
Framing {Only after Plbg.. i;.lec.. MaCh and Fire) "1/9/0'1 ~
Insulation (SoundlEilergy) I
Do not tape or plaste,r 'until the fol/owing applicable
items have been signed:, '
Dryw",n ' ' " ,
PenetratiOllS (Fire Rated) Electrical ' , ,
Penetrations (Fire Rated) Mechanical
Penetrations (Fire Rated) Plurnbil1\l
Interior Lath
Exterior Lath ' ,
, , ' GENERAL ITEMS " '
Exterior Plaster (Brown Coal)
T.Bar 'Electrical
T -Bar Mechanical , "
T -Bar Structural " ' ",
Sewer ' '
Water Engineering Backflow ' '
Water Service ' ' . ' "
FINAL INSPECTIONS
Electrical Final
Plumbing Final
Mechanical Final
Gas Test
Engineering/Grading Final 765-5126
Dale
Inspector
(l
~
Fire Dept. Final,765,-4040
Water Engineering 765-5268
SubL.ist/Business License '765-519
Zoning 765-5139
Build,ngFin," (Last Inspection- Only ,
, After Above,Completel
PARTIAL INSPECTIONS,
BuildinQ Inspections
Mechanical Inspections
Plumbina Inspections
Electrical Inspections