417 S AGATE STPermit Types
i BLD ELE I MEC PLM
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Permit Number: OLD2023-01528
Issued: 03/31/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 40
Site Address: 417 S AGATE ST, ANAHEIM, CA 92804
Legal Description: N TR 2501 BLK LOT 8
APN: 12814404
OWNER - BUILDER DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
I hereby affirm under penalty of perjury that 1 am exempt from the Contractors License State taw for the following reasons) Indicated below by the
eheckmark(s) I have placed next to the applicable Item(s) (Sec. 7031.5 Business and Professions Code: any city or county which requires a perm 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 0 (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 dollen ($500).
0[ 1, as owner of property, or my employees with wages as their sole compensation, will do i I all or L) portions of the work, and the structure Is not intended or
JJJ offered for sale (See. 7044 Business and Professions Code: The Corhtraaors' State License Law does not apply to an owner of property who, through employees' or
personal efforts, builds or Improves the property, provided that the Improvements are not Intended or offered for sale. t, 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).
1, as the owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sec. 7044 Business and Professions Code:
The Contractors' State License Law does not appy to an owner of property who builds or Improves thereon, and who contracts for the projects with a licensed
Contractor pursuant to the Contractor's State License Lew).
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: hto://www.lecinfo.co.cov/calaw.html.
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the property owner's 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 city or county to enter the above-identBed property for inspection purposes.
m- 3 > A?yCz3
Signature of Property Owner or Authorized Agent Date
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' 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
AS PROVIDED FOR IN SECTION 3706 OR THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I 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.
I have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Carrier: Policy No.: Expiration Date:
Name of Agent:
Phone No.:
I 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
worker's compensation laws of California, and agree that, it 1 should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
Signature of Applicant
Date
DECLARATION REGARDING 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
(Sec.3097.Civ.C):
Lender's Name: .
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
1 hereby affirm under the 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.
Contractor Signature" Date
NUMBER EXPIRATION DATE LICENSE TYPE (Sl