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2533 E SEVILLE AVEPermit Types BLD ELE MEC PLM CITY OF ANAHEIM X BUILDING DIVISION Permit Number: OLD2022-05553 200 S. ANAHEIM BLVD. Issued: 11/21/2022 www.anaheim.neUbuilding (714)765-4626 Quarter Section: 122 Site Address; ;2533 E SEVILLE AVE, ANAHEIM, CA 92806 legal DeseAptionc.N,TR 276TBLK LOT 46 ._ .;. . APN: 2682 t7223 ' Project Description: Residential Level 2 EV Charger Living Area: Number of Stories. Garage Area: Carport Area: Balcony I Deck Area: Cool Roof - People Associated with Project: Permit Applicant Jeremiah Bright Owner KINCAID WILLIAM D TR (7141 765 - 5153 0 Valuation: 0.00 Constriction Types: NIA Occupancy Groups: Fire Spdnklered: Total Fees paid for Permit: 167.00 18032 WELLINGTON CIR Type Electrical Fixtures Qty Type Plumbing Fixtures Qty Mechanical Fixtures City EV Charger 1 The permit shall expire by limitation and become null and void If the building or work has not passed Anal Inspection 365 days from the date of permit issuance. A new permit is required to commence or continue work. P�pHEIM cqC City of Anaheim o� io Building Division F i u a �DUNDED �ay� 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 IZ,4124 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 List/Bus. 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 sianed7 Building Final (714 765-5153) Last Inspection-Final Only After Above Completed Plumbing (Ground/Underfloor Water) Underfloor Rough Gas PARTIAL INSPECTIONS Buildinq Inspections Mechanical (Groundwork) Electrical (Underground Conduit) Pre-slab (Compaction/Membrane Reinf.) Floor (Joist/Girders) Underfloor Insulation (Raised Foundation Only) Floor Nailing (Raised Foundation Only) 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 Sewer Water Engineering Backflow (Testable Only) Water Service ?^s33 SEALtt 8LJD =-- 095eS L•uA"x1lg1'�`+�� a=122 J � I RESIDENTIAL GUIDELINE FOR ELECTRICAL VEHICLE (EV) CHARGER INSTALLATION The purpose of this guideline is to assist homeowners and contractors in streamlining the permitting and installation process for home EV Charging Stations Thank you for considering the use of electricity as an alternative fuel source for your next vehicle. There are 2 basic types of EV Chargers for home use (Level 1 and Level 2). Level 1 Chargers are smaller units that plug directly into a standard 120 volt receptacle outlet. These types of Chargers typically require a longer period of time to recharge the vehicle. As long as the receptacle outlet being used to plug-in the Level 1 Charger is existing, there is no requirement to secure a permit from the Building and Safety Division. On the other hand, if you will be installing a new 120 volt receptacle outlet for the Charger, you will need to obtain a permit - but you will not need to provide any plans or electrical load calculations as would be required for the more powerful Level 2 type Charging systems. A Level 2 EV Charging system requires 240 volts and charges the vehicle much faster than a Level 1 Charger. Level 2 Charger installations require a permit from the City. In order to obtain the permit you will need to provide the City with some basic information to show that your existing electrical service can handle the added load. If a service upgrade is necessary, please contact the Utilities Department for the required "meter spot" report. What information do I need to provide the City in order to obtain the permit? The City of Anaheim has developed this "EV Charger Installation Guideline" in order to streamline the permit and installation process. In most cases, you or your contractor merely need to fill-in the blanks on this document, attach the manufacturer's installation instructions and Charger specifications, and submit it to the Building Division for an over-the-counter review and permit issuance, or complete the application online. If all of the information is provided and the proposal complies with the applicable codes, the review and approval process will only take a few minutes. Once the permit is issued the installation may begin. Upon completion of the installation, an inspection will need to be scheduled to inspect the work performed. The inspection request will need to be scheduled through the Anaheim Building Division and is requested and scheduled by the customer. Inspections are typically performed on the work day following your request for inspection. Please keep in mind that someone will need to be present during the inspection so that the Building Inspector can access the location of the EV Charger, which is typically located in the garage. Approval must also be granted by the Utilities Department for the EV Charger installation. Page 1 of 5 Sep 2016 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax B837 www.anaheim.net/building ' `'dlrstalling•a level 2 EV Charging System often requires changes to building wiring and Utility electric is ces. Before installi Mg�cpharging equipment and associated infrastructure, talk to your EV manufacturer 4. +for ii dr , dI&I abolt what you need to charge your vehicle. If separate Contractors are used for the infrastructure wiring and the EV installation, separate permits will be required for each portion. When Installing ur EV Charger, be sure to use a licensed Electrical Contractor whose license is current for electrical work. The Contractor shall follow the guidelines of the manufacturer and all necessary Code requirements. When mechanical ventilation is required for the EV Charger, an additional mechanical permit will be required. Why is the Electric Utility concerned about your EV Charger Installation? Although an individual Level 2 EV Charger may have a negligible impact on the Public Utilities electric system, the combined effect of several EV Chargers in the same area could result in overloads on Utility secondary wires and transformers. It is crucial that the City of Anaheim be notified of any Level 2 Charger installations to ensure the Utility electrical system components are adequately sized to maintain high levels of service reliability. For more information, please contact the City of Anaheim's Public Utilities Department at 714-765-7438. This information can also be accessed on the Public Utilities webpage at www.anaheim.net or you can visit Public Utilities Electrical Engineering, located on the 7th floor at 201 South Anaheim Blvd., Anaheim, CA. 92805. LEVEL 2 ELECTRIC VEHICLE CHARGER - SERVICE LOAD CALCULATION INSTRUCTIONS: Review the list of electrical loads in the table below and check all that exist in the home (don't forget to include the proposed Level 2 EV Charger). For each item checked, fill-in the corresponding "Watts used" (refer to the "Typical Usage" column for wattage information), then add up all the numbers written in the "Watts Used" column. Write this number in the "Total Wafts Used" box at the bottom of the table and proceed to the next page. Page 2 of 5 Sep 2016 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax B837 www.anaheim.net/buildinp EXISTING MAIN CIRCUIT BREAKER SIZE: 2-970 AMPS *(Loads shown are rough estimates; actual loads may vary - for a more precise analysis, use the nameplate ratings for appliances and other loads and consult with a trained electrical professionaQ. Check All Applicable . Loads Description of Load Typical Usage* Wafts Used GENERAL LIGHTING AND RECEPTACLE OUTLET CIRCUITS Multiply the Square foota a of house X 3 3 watts/sq.ft. sf �i�0 KITCHEN CIRCUITS Kitchen circuits 3,000 watts O Electric.oven 2,000 watts Electric stove top 5,000 watts Microwave 1,500 watts 1. $C90 Garbage disposal under kitchen sink 1,000 watts It 000 Automatic dish washer 3,500 watts s00 Garbage compactor 1,000 watts Instantaneous hot water at sink 1,500 watts LAUNDRY CIRCUIT -Laundry circuit 1,500 watts I VD Electric clothes dryer 4,500 watts HEATING AND AIR CONDITIONING CIRCUITS Central heating (gas) and air conditioning 6,000 watts 6J app Window -mounted A/C 1,000 watts Whole -house or attic fan 500 watts Central electric furnace 1 8,000 watts Evaporative Cooler 1 500 watts OTHER ELECTRICAL LOADS Electric water heater (storage type) 4,000 watts Electric tank less water.heater 15,000 watts . Swimming pool or spa 3,500 watts Other: describe ELECTRIC VEHICLE CHARGER CIRCUIT E ISSUANCE OF s Level 2 Electric Vehicle Charger rating* *Use nameplate rating In watts or calculate as: (Ampere rating or circui apfis = Watts) TV41S PER .1 NY OF l y� Igo E d of I%d� §f� T.Y. you have checked) ROCEEDS A7 HIS OWN RISK. TOTAL WATTS USED mo 3G,, 3�� t -'V 21 2022 BUILDING DIVISION OF ANAHEIM APPROVED_ 21� quo Page 3 of 5 Sep 2016 �-��Ayhelmlvd., w e 45 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax 8837 www.anaheim.net/building INSTRUCTIONS: Apply the Total Wafts Used number from the previous page to the table below to identify if the existing electrical service panel is large enough to handle the added electrical load from the proposed Level 2 EV Charger. If your electrical service is NOT large enough, then you will need to install a new upgraded electrical service panel. Please note that the size of your existing service must be equal to or larger than the minimum required size identified in the table above or a new upgraded electrical service panel will need to be installed (a separate permit is required for new service). Please note that approval from the Utilities Department will be required for the installation of the new electrical service panel. CAUTION: This table is NOT to be used to determine the size of a NEW UPGRADED electrical service panel if your existing panel is too small or overloaded according to the table above. In order to determine the size of a NEW dr UPGRADED service panel, there is a completely different load calculation methodology that applies. Sizing of a NEW or UPGRADED electrical service panel should only be done by a qualified Electrical Contractor or Electrical Engineer. STATEMENT OF COMPLIANCE By my signature, I attest that the information provided is true and accurate. Job Address: 2S 3 j5� Soedi ref' t job address) Signature: (Si ature applicant) (Date) Please note that this is a voluntary compliance alternative and you may wish to hire a qualified individual or company to perform a thorough evaluation of your electrical service capacity in lieu of this alternative methodology. Use of this electrical load calculation estimate methodology and forms is at the user's risk and carries no implied guarantee of accuracy. Users of this methodology and these forms are advised to seek professional assistance in determining the electrical capacity of a service panel. Page 4 of 5 Sep 2016 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax B837 www.anaheim.net/buildinq Minimum Required Size of Existing 240 Total Wafts Used Total Wafts Used /Check Volt Electrical Before Adjustments the Service Panel appropriate (Main Service line Breaker.size 6 Up to 48,000 100 amps 48,001 to 63,000 125 ctm s 63,001 to 78,000 150 amps 78,001 to 108,000 200 amps 108,001 to 123,000 225 amps Please note that the size of your existing service must be equal to or larger than the minimum required size identified in the table above or a new upgraded electrical service panel will need to be installed (a separate permit is required for new service). Please note that approval from the Utilities Department will be required for the installation of the new electrical service panel. CAUTION: This table is NOT to be used to determine the size of a NEW UPGRADED electrical service panel if your existing panel is too small or overloaded according to the table above. In order to determine the size of a NEW dr UPGRADED service panel, there is a completely different load calculation methodology that applies. Sizing of a NEW or UPGRADED electrical service panel should only be done by a qualified Electrical Contractor or Electrical Engineer. STATEMENT OF COMPLIANCE By my signature, I attest that the information provided is true and accurate. Job Address: 2S 3 j5� Soedi ref' t job address) Signature: (Si ature applicant) (Date) Please note that this is a voluntary compliance alternative and you may wish to hire a qualified individual or company to perform a thorough evaluation of your electrical service capacity in lieu of this alternative methodology. Use of this electrical load calculation estimate methodology and forms is at the user's risk and carries no implied guarantee of accuracy. Users of this methodology and these forms are advised to seek professional assistance in determining the electrical capacity of a service panel. Page 4 of 5 Sep 2016 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax B837 www.anaheim.net/buildinq Permit Types BLD ELE MEC PLM X Permit Number. BLD2022-05553 Issued: 11/21/2022 www.anaheim.neUbuilding (714)765.4626 Quarter Section:122 Site Address: 2533 E SEVILLE AVE, ANAHEIM, CA 92806 Legal Description: N TR 2767 BLK LOT 46 APN: 26827223 OWNER - BUILDER DECLARATION: CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 5153 1 hereby affirm under penalty of perjury that 1 am exempt from the Contractors License Stats Law for the following mason(s) 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 g (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 mora than five hundred dollars ($500). 1, as owner of property, or my employees with wages as their sole compensation, will do I I all or U 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 bulli or Improved for the purpose of sale). 1, as the owner of the property, am exclusively contracting with licensed Contractors to construct the project (See. 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 Contractors State License Law). 1 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 entirely 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:lhvww.leainfo.co.aovLcalaw.html. By my signature below, l 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 1 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 -identified property for inspection purposes. /l/'2-Vz2 a re e� Own iodized 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. 1 hereby affirm under penalty of perjury one of gra following declarations: I have and will maintain a certificate of consent to selfinsure 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 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, end 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 provlslons. 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: I 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 (Si Permit Number: BLD2022-05553 Issued: 11/21/2022 www.anaheim.net/building (714)765-4626 Quarter Section: 122 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (7141 765 - 5153 OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION FORM Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at 2533 E SEVILLE AVE. ANAHEIM. CA 92806. 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 us 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. I, 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 homeowner's 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 /#0-007 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 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. 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. 176 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: 2533 E SEVILLE AVE. Permit Number: BLD2022-05553 Issued: 11/21/2022 www.anaheim.neUbuilding (714)765-0626 Quarter Section: 122 Permit Number: BL02022-05553 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. 1714) 765 - 5153 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 presented when the permit is issue o verify the property owner's signature. /2//�ZZ rty Owne Signature Dat : CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION AUTNORIZATION OF AGENT TO ACT ON BEHALF OF PROPERTY OWNER FORM *Per California State Law, if you, the property owner, will be coming to our office to get a permit, we do not require you to complete this form, however, if you are sending someone on your behalf (your agent), please complete and sign the information below. Also make sure that you have provided your agent with a signed Owner -Builder Acknowledgment and Information Verification Form. .- Project Project Location or Address: _ Address of Authorized Agent: _ , - _ _ - Phone Number of Authorized -7l4-2414-o2.1 Required Forms of Identification Attached: (Please check one of the forms of identification below in addition to the required California State Issued ID) Property Owner's California State Issued ID with: Property Deed Property Tax Bill Closed escrow document Title Search Mortgage Bili I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above into ti n rtify its accuracy. Property Owner's Signature: Date: Office Use Only: , ID Verified d Ownership Verified Documents Planning Info Permit # 910.2a) -- ol�Y55 3 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765,5153 Phone (714)7654807 Fax OCT 2013 www.anaheim.nel1building B720 CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION OWNER -BUILDER ACKNOWLEDGMENT AND INFORMATION VERIFICATION FORM *Per California State Law, if you, the property owner, will be coming to our office to get a permit, we will provide you with this form when you arrive. If you are sending your agent, please complete, initial, and sign the Information below. Also make sure that you have provided your agent with a signed Authorization to Act on Behalf of the Property Owner Form with the required forms of identification. Dear Property Owner. An application for a building permit has been submitted in your name listing -yourself as the builder of the property improvements specified at We are providing you with an Owner -Builder Acknowledgment 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 us 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. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each statement below to signify you understand or verify this information. VUL1. I 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. I, 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 homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. �1>'� 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. �L'3 I understand as an "Owner -Builder I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. . I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. ut I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value 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. �66. I understand if 1 am considered an "employer under state and federal law, I must register with MARCH 2009 200 S. Anaheim Blvd., Sufte 145 Anaheim. California 52605 (714)765-5153 Phone (714)765.4607 Fax :t B%Z� -`-°—--.ti..����-- the state and federal govemment, withhold payroll taxes, provide workers' 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. V 6gle .Iunderstand under California Contractors' State License Law, an Owner -Builder who builds -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. . I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be Yeld—liable for any financial or personal injuries sustained b subsequent Y any eq owner(s) that result from 1 any /latent construction defects in the workmanship or materials. Vc'9.1 understand I may obtain more information regarding my obligations as an "employer" from the Intemal Revenue Service, the United States Small Business Administration, the Callfomia Department of Benefit Payments, and the Califomia Division of Industrial Accidents. I also understand I may contact the California Contactors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 0. I 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„„.,,, _ _. , . , — - i ' . _ _ ., ., A --J ft U . I agree that, as the party legally and financially responsible for thisro osed P p construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. &412'. 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 financial loss 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 presented when the permit is issued to verify the property owner's signature. _ Property Owner's '&, �Q, - 7, Z, / AGE 2 OF 2 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)7655153 Phone (714)785.4807 Fax E172172� P�