927 S AGATE STPermit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05181
Issued: 11/01/2022
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 41
Site Address: 927 S AGATE ST, ANAHEIM, CA 92804
Legal Description: Ni TR 2426 BLK LOT 7
APN:12830407
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
17141 765 - 5153
Project Description: Electrical 200amp main panel upgrade for main house
Living Area: Number of Stories: 1 Valuation: 0.00
Garage Area: Construction Types: NIA
Carport Area: Occupancy Groups:
Balcony I Deck Area: Fire Sprinldered:
Cool Roof: Total Fees paid for Permk: 167.00
People Associated with Project:
Permit Applicant Jason Vong
Owner VONG JASON 17140 JUNIPER ST
Type Electrical Fixtures City Type Plumbing Fixtures City Mechanical Fixtures Oty
Meter/Disc Sw - Under 600 V, up to 200 1
amps
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 permit is required to commence or continue work.
P�pNEIM C9C
City of Anaheim o� �o
Building Division F z
u >
�OGNnEo �$y^
Do not occupy this building until the final inspections have been made.
FINAL INSPECTIONS DATE INSPECTOR
All applicable items below must be signed before utilities are released
Final Gas Test '
Electrical Final
Plumbing Final
Mechanical Final
Cross Connection Control (714) 765-4280
Engineering Final (714) 765-5126
INSPECTION I DATE INSPECTOR
Fire Sprinkler (ONLY) (714) 765-5041
Do not pour concrete until the following applicable items have been signed:
Fire Dept. Final (714) 765-5041
Plumbing (Ground/Underfloor Drain Waste)
Water Engineering (714) 765-4591
Electrical Ground Electrode/Ufer
Sub LisUBus. Lic. (714) 765-5194 (Allow 10 business days)
Setback/Forms/Trenches (Footings)
COA/Migation Measures
Do not install subfloor or pour floor slab until the follwing applicable items have been
siane .
Building Final (714 765-5153)
Last Inspection -Final Only After Above Completed
Plumbing (Ground/Underfloor Water)
Underfloor Rough Gas
PARTIAL INSPECTIONS
Building Inspections
A
Mechanical (Groundwork)
Electrical (Underground Conduit)
Pre -slab (Compaction/Membrane Reinf.)
Floor (Joist/Girdem)
V I
Underfloor Insulation (Raised Foundation Only)
Floor Nailing (Raised Foundation Only)
M. .T -
2nd Floor (Floor Nailing)
Do not cover or conceal the work below until the following applicable items have
been e•
1st Floor Shear
Firesprinkler (Rough) (Fire Dept.)
Mechanical Inspections
2nd Floor Shear
Roof (Sheathing/Diaphragm/Frame)
Masonry (Reinf./Bond Beam/Pre-Grout)
Rough Plumbing (Top Out)
Rough Duct (Mechanical)
Rough Mechanical
Rough Electrical
Rough COA/Mitagation Measures
Plumbing Inspections
Framing (Only after Plbg., Ele., Mec. & Fire)
Insulation (Sound/Energy)
Do not tape or plaster until the following applicable items have been signed:
Drywall
Drywall Penetrations (Ele, Mec & Plbg)
Interior Lath
Exterior Lath
Electrical Inspections
Electrical Service Meter -(Meter will be set within 2-3
business days after approval) Excludes New
Construction
Exterior Plaster (Brown Coat)
T -Bar (Struct., Ele., or Mec.)
Grease Interceptor
(Do no
Sewer
Water Engineering Backflow (Testable Only)
Water Service
Pcsmlt Number: BLD2022-05181
Issued:
www.anaheim.net/building
(714)765-0626
Quarter Section: 41
Dear Property Owner:
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765.5153
OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION FORM
An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements
specified at 927 S AGATE ST. ANAHEIM, CA 92804.
We are providing you with an Owner -Builder Acknowledgement and Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder.
We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this
form to tis at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner,
obtain the prior approval of the permitting authority.
Directions: Read and initial each statement below to signify you understand or verify this information.
1.1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" building
permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an
Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. My homeowners insurance may not provide coverage for those
injuries. I am willfully working as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to
2.1 understand building permits are not required to be signed by property owners unless they are responsible for the
construction and are not hiring a licensed Contractor to assume this responsibility.
3.1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
myself from potential risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
/ 5.1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
(v�V of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
j 6.1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal
government, withhold payroll taxes, provide workers's compensation disability insurance, and contribute to unemployment
compensation for each "employee". I also understand my failure to abide by these laws may subject me to serious financial
risk.
7.1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
8.1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial
or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
9.1 understand I may obtain more information regarding my obligations as an "employer' from the internal Revenue Service,
the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at
1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors.
10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party legally and financially responsible for proposed construction activity at the following address: 927 S AGATE ST.
CITY OF ANAHEIM
BUILDING DIVISION
Permit Number. BLD2022-05181 200 S. ANAHEIM BLVD.
Issued: i 17141 765 - 5155
www.anaheim.neUbuilding
(714)765.4626
Quarter Section: 41
Permit Number: BLD2022-05181
11.1 agree that, as the party Legally and financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
12.1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a license, the Contractors' State License Board may be unable to assist you with any
financialloss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil
court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is
injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and
wish to hire
Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of
their workers' compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the
agency responsible for issuing the permit.
Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency is required
to be presep" i Then the permit is issued to verify the property owner's signature.
oRo1 v
Signature
Dath:
Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2022-05181
Issued: 11/01/2022
www.anaheim.neUbuilding
(714)765-4626
Quarter Section: 41
Site Address: 927 S AGATE ST, ANAHEIM, CA 92804
Legal Description: N TR 2426 BLK LOT 7
APN: 12830407
OWNER - BUILDER DECLARATION:
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(7141 765 - 5153
I hereby affirm under penalty of perjury that I am exempt from the Contractor's License State Law for the following reasons) Indicated below by the
checkmark(s) I have placed next to the applicable Item(s) (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 the permit to file a signed statement that he
or she Is licensed pursuant to the provisions of the Contractors' State License Law Chapter a (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).
1, as owner of property, or my employees with wages as their sole comPensation, will do I l ell or (_) portions of the work, and the structure Is not Intended or
offered for sale (Sec. 7044 Business and Professions Code: The Contractors' 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. 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).
1, as the owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sec. 7044 Business and Professions Code:
The Contrectors' State License Lew does not apply to an owner of property who builds or Improves thereon, and who contracts for the projects with a licensed
Contractor pursuant to the Contractors State License Law).
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 1 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: htto://www.leainfb.ra.aov/colaw.htmi.
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 tfQnply with all applicable city and county ordinances and state laws relating to building construction
of this city or county to enter the above -Identified property for inspection purposes
) �� A
Owner or Authorized Agent Dat
WORKER'SX41IMPENSATION 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 effirn under penalty of pedury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for worker's 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 workees Compensation insurance carrier and policy are:
Cartier: 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
workers compensation laws of California, and agree 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.
Signature of Applicant
Date