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CITY OF ANAHEIM
PLANNING SERVICES DIVISION
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BY
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Exemp; ❑ er ,500 ftI
Plans comply with rifle 18 of the A.M. C. (Zoning).
This does not constitute approval of a building MAR 21 2023
permit or authorize violation of any City Codes.
CITY OF ,;,yA; {FI,19
C 0t me, 0 fi PLANNING & BUILD,
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FINAL
®ATE: 3 29 2
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OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the
Contractors' State License Law for the reason(s) indicated below by
the checkmark(s) I have placed next to the applicable item(s)
(Section 7031.5, Business and Professions Code): Any city or county
that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to
the provisions of the Contractors' State License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code) or that he or she is exempt from licensure 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).)
L_) 1, as owner of the property, or my employees with wages as
their sole compensation, will do U all of or L) portions of the
work, and the structure is not intended or offered for sale (Section
7044, Business and Professions Code: The Contractors' State
License Law does not apply to an owner of property who, through
employees' or personal effort, builds or Improves the property,
provided that the improvements are not intended or offered for sale.
If, however, the building or improvement is sold within one year of
completion, the Owner -Builder will have the burden of proving that it
was not built or improved for the purpose of sale.)
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044, Business
and Professions Code. The Contractors State License Law does not
apply to an owner of property who builds or improves thereon, and
who contractors for the projects with a license Contractor pursuant to
the Contractors' State License Law.).
U I am exempt from licensure under the Contractors' State License
Law for the following reason:
By my signature below I acknowledge that, except for my personal
residence in which I must have resided for at least one year prior to
completion of the improvements covered by this permit, I cannot
legally sell a structure that I have built as an owner -builder if it has
not been constructed in its entirety by licensed contractors. I
understand that a copy of the applicable law, Section 7044 of the
Business and Professions Code, is available upon request when this
application is submitted or at the following Web site:
http://www.feginfo.ca.gov/calaw.htmi.
Date:
Signature of Property Owner of Authorized Agent
.. +s. "'' .. :COLUMN 2 • +' •r, • • t
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of Division 3
of the Business and Professions Code, and my license is in full force
and effect.
License Class License No.
Date Contractor Signature
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKER'S COMPENSATION
COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES ARE PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
_ 1 have and will maintain a certificate of consent to self -insure for
workers' compensation, issued by the Director of Industrial Relations
as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Policy No.
_ I have and will maintain workers' compensation insurance, as
required by Section 3700 of the Labor Code, for the performance of
the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
_ 1 certify that, in the performance 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 workers' compensation laws of California, and
agree that, if I should become subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I shall forthwith comply
with those provisions
Signature of Applicant
JOB ADDRESS
LOCALITY
y •COL'UMN`S.,.-.-
' HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous material
information guide?
s `
Yes ❑ No ❑
i#
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or modification
from the South Coast Air Quality Management District
(SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑
1 have read the hazardous materials information guide and the A
SCAQMD permitting checklist. I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220 Sections
220.100 through 220.140 concerning hazardous material reporting
and for obtaining a pernit from the SCAQMD.
��
ASBESTOS NOTIFICATION
❑ Notification letter sent to SCAQMD or EPA t
❑ 1 declare that notification of asbestos removal is not applicable ^mss
to addressed project. a �►�
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY a
1 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 (Section 3097, Civil Code)
Lender's Name
Lenders Address
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the property
owners behalf.
I have read this application and the information I have provided is
correct.
I agree to comply with all applicable city and county ordinances
and state laws relating to building construction.
I authorize representatives of this county to enter the above -
identified property for inspection purposes.
Signature of Property Owner or Authorized Agent
Date
Date