5741 E. Santa Ana Canyon Rd.
OWNER-BUILDER DECLARATION
ere ya irm under penalty 0 perjury that am exempt rom the on tractor's Llqense Law or the 0 Jowlng reason ee. 7031.5 Business an
Professions Code: any city or county which requires a permit to construct, alter, j,nprove, 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 ':;ode) 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 penalty of not more than five hundred dollars
($500).
o I, as owner of property, or my employees with wages as their sole compens,.ltion, 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 joes 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 enlployees, provided that such improvements are not intended or
offered for sale. If, however, the building or improvement is sold with one year 0'. completion, the ownerRbuilder will have the burden of proving that he
did not build or improve for the purpose of sale).
o I, as the owner of the property, am exclusively contracting with licensed cOr'!tractors 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....qontractor(s) licensed pursuant to the Contractor's License Law).
U 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 selfRinsure for worker's c('mpensation,
as provided for by Section 3700 of the Labor Code, for the pelformance of the 'Ii,)fK for which
this permit is issued.
~ have and will maintain worker's compensation insurance, as required by Section 3700 of
the Labor Code, for the pertormance of the work for which this permit is issued. ,My worker's
Compensation insurance carrier and policy are:
Carrier: STATE COMPENSATION INS. FUND. Policy Number. 0012264-2013
This section need not be completed if \he pennit is lor one hundred dollars ($100) or less.
o I certify that in the pertorrnance 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 Califomia, and agree that if I should become subject to the worker's ompensation
provisions of Section 3700 of the Labor Code, I shall forthwith comp' with those provisions.
Date: 10/10/2005 Applicant: ~
WARN ING: FAILURE TO SECURE WORKER'S COMPENSA N COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL
FINES UP TO ONE HUNDRED TI-lOUSAND DOLLARS ($100,000), IN ADDITION 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
pertormance of the work for which thisperri1it is issued (Sec.3G97.Civ.C}:
Lender's Information:
BUILDING PERMIT NO. BLD2005-01148
TYPE OF PERMIT
Tenant Improvement (Limited) CITY
DATE: 10/10/2005
JOB ADDRESS: 5741 E SANTA ANA CANYON RD
LEGAL DESCRIPTION: DOMINGUEZ ESTATE LOT 4 POR OF LOT
APPLICANT: EDMUND DIGOTT
OWNER INFORMATION: CONTRACTOR INFORMATION:
IMPERIAL PROPERTIES HEIMAN CONSTRUCTION COMPANY
2424 SE BRISTOL ST #200 722 GENEVIEVE ST #1
NEWPORT BEACH, CA 92660 0000 SOLANA BEACH, CA 92075 0000
JOB DESCRIPTIONlenant improvement - Starbucks Coffee (originally received as: 5747)
VALUATION: 120,000.00
ElM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
INSPECTION REQUEST LINE:
(714) 765 - 4626
CENSUS CODE: 437
QUARTER SECTION: 185
ARCHITECT/ENGINEER INFORMATION:
HOSSEIN M HOSSEINAN
2401 UTAH AVENUE SOUTH
SEAlLE, WA 98134 0000
PROCESSED BY: GAQ
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 bu ilding construction, and
hereby authorize representives of this ci to enter upon the above mentioned property for
i~ect~n purposes. 0
/ c;/' Date: 10/10/2005
Signature of Appli 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 permt is required to commence or continue work.
LICENSED CONTRACTORS DECLARATION
ere ya Irm un er pena ty 0 perjury t at am
licensed under provisions of chapter 9 (commencing
with Section 7000) of Oivsion 3 of the Busin and
profess~~~s ~.
10/10/~
Date:
NUMBER
446698
TYPE
EXPIRATION DATE
1013112007
B
Construcion Types:
VN, ,
Occupancy Groups:
B, , , ,
Fire Sprinklered?
T.J.Area:
YES
1,799
Fees paid for Permit:
Total:
3,648.57
City of Anaheim
Building Division
INSPECTION RECORD
INSPECTION DATE INSPECTOR
Temporary Power Pole
Plumbing (DrainlWaste Pipe) IIJII/rJtlI ;!au'
Electrical Ground Electrode/Ufer
Setback/Forms/Trenches (Footings)
Do not Install sublloor or pour Iloor slab until the
following applicable Items have been signed:
Plumbing Jl4'fdfer P.lPMSprinkler Valves) lacrlGlr ~
Mechanicar(Groundwork) I
Electrical (Underground Conduit) ''<<If
'Pre:'slab-{Compaction/Membrane Reinf.) ~{I'1Iif" '-1,
I.J,J.rde'rpinning (Floor Joist/Girders)
Do not cover or conceal the work below until the
following applicable Items have been signed:
1 st Floor Shear
Firesprinkler (Rough)
2nd Floor Shear
Roof (Sheathing/Diaphragm/Frame)
Masonry (Reinl./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 (Sound/Energy)
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 Coat)
T..Bar Electrical
T-Bar Mechanical
T-Bar Structural
Sewer
Water Engineering Backflow
Water Service
FINAL INSPECTIONS
Electrical Final
Plumbing Final
Mechanical Final
G Test
ngineering/Grading Final 765-5126 l'l-\
ire Dept. Final 765-4040 nf
ater Engineering 765-5268
Sub List/Business License 765-5194
Zoning 765-5139
Building Final (L881lnspaclion. Only .1
Aller Above COmplete) ll4
INSPECTOR
,??
PARTIAL INSPECTIONS
Building InsDections
Mechanical Inspections
Plumbina InsDections
ElectricallnSDections