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1625 S LEWIS ST (16)Permit Types BLD ELE MEC PLM X Permit Number: BLD2023-02123 Issued: 05/17/2023 www.anaheim.net/building (714)7654626 Quarter Section: 97 Site Address: 1625 S LEWIS ST, Anaheim, CA 92805 Legal Description: P BK 234 PG 8 PAR 1 APN: 08224110 OWNER - BUILDER DECLARATION: CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765.5153 I hereby affirm under penalty of perjury that I am exempt from the Contractor's License State Law for the following reason(s) Indicated below by the checkmark(s) I have placed next to the applicable Rem(s) (Sec. 7031.5 Business and Professions Code: any city or county which requires a permit to construe% 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 chril 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 (_J all or L_) 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 Contractors' State License low 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 Contrectoes State License law). I em exempt from licensure under the Contractors, State License Law for the following reason: By my signature below 1 acknowledge that, except for my,pefsonal 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. l 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:Mxww.leainfo.ca.aov/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 owners behalf. I have read this application and the information I have provided Is correct. 1 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 above4dentified property for inspection purposes. 5/1-7/2)23 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 selfansure 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, l 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): Lenders Name: I Pndpr'c Addrpcs• LICENSED CONTRACTOR'S DECLARATION: I hereby affirm under the penalty of Pequry 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 (S)