1515 S HARBOR BLVD 305 (22)Per%1i;
BLD ELEM
X X
Permit Number: BLD2023-01810
Issued: 05/04/2023
www.anaheim.neUbuilding
(714)765.4626
Quarter Section: 76
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1515 S HARBOR BLVD 305, Anaheim, CA 92802
Legal Description: S TWP 4 RGE 10 SEC 22 T4 R10 SEC 22 POR OF W 1/2
APN: 08219027
OWNER - BUILDER DECLARATION:
I hereby affirm under penalty of perjury that 1 am exempt from the Contractors License State Law for the following reason(*) 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 B (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).
I, as owner of property, or my employees with wages as their sole compensation, will do I l all 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 Lew does not appy 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
{ wilhln one year of completion, Ore Owner -Builder will have the burden of proving that it was not built or improved for the purpose of sale).
Q% I, 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 apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed
Contractor pursuant to the Contrector's State License Law).
I em exempt from licensure under the Contractors, State License Lew 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 1 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: htti)Avvw.leainfo.ca.aovlcalow.html.
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the properly 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 misting to building construction
I authorize representatives of this city or county to enter the above -identified property for inspection purposes.
- 51,q lab 23
ignature of ropety Owner or Autho gent 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 self4nsure 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 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 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 workers 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 pedury 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 (S1