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6435 E SHADY VALLEY LN (3)Permlt Types BLDG• ELE MEC PLM X Perfult Number: OLD2023-02461 Issued: 05/18/2023 www.anahelm.net/building (714)7654626 Quarter Section: 205 CITY OF ANAHEIM Site Address: 6435 E SHADY VALLEY LN, ANAHEIM, CA 92807 Legal Description: N TR 9213 BLK LOT 36 APN:36525132 OWNER - BUILDER DECLARATION: BUILDING DIVISION 200 S. ANAHEIM BLVD. (?14M-6153 1 hereby affirm under penalty of perjurythat I am exempt from the Contraatore License State Law forthe following reeson(s) Indicated below by the checkmark(s) I have placed next to the applicable Itetn(s) (Sec. 7031.5 Business and Professions Code: any city or county which requires a permit to construct, after, 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 provi Ions of the Contrectors' State License Lew Chapter 9 (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 MIA by any applicant for a permit subjects the applicant to a civil penalty of not mote than five hundred dollars (5600 1, as owner of property, or my employees with wages as their ado compensation, will do"all or L__) potions of the work and the structure Is not intended or offered for sate (&x 7044 Business and Professions Code, The Contractors' Suite License Law does not appy to an owner of property who, through employees' or personal efforts, builds or improves the properly, provided that the improvements are not intended or offered for sale. If, however, the building or Imp ovemert Is sad vMn 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 properly, am exclusively mntrecting with licensed contractors to construct the projed (Seo. 7044 Business and Professlons Coda The Contractors' State License Lew does not appy to on owner of property who builds or Improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contredcre State license Lew). I am exempt ham licensure under the Contractors, State License Law for the following reason: By my signature below 1 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, l cannot legally sell a structure drat I have built as an owner4xdlder O it has not been constructed In its entirely by licensed contrators. I understand 00 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:IMmiwJealnbm.novlcalaw.html. By my signature below, l certify to each of the following: I am the property owner or authorized to ad on the property owners behalf. 1 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 liana relating to building construction 1 authorize representatives of this dy, or county to enter the aboveddentiffed property for Inspection purposes. 4=L Signature of Proa Owner or Authorized Agent - Date— WORKER'S ate— 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 (3100,000). 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 seiransure for w orkere 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: 1 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: Carter. Policy No.: Expiration Data: Name df Agent: Phone No: I certiy that In the perfomwrhce of the work for which this permit is Issued, I shag not employ any person in any manner so as to become subject to the workers compensation laws of Cardomla, and agree that, O I should become subject to the workers compensation previsions 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.W.C): Lenders 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 M Permit Number: BLD2023-02461 Issued: 05/18/2023 www.anaheim.net/building (714)7654626 Quarter Section: 205 CITY OF ANAHEIM BUILDING DMSIDN 200 & ANAHEIM BLVD. (714) 765 -6153 OWNER43UILDER 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 6435 E SHADY VALLEY LN. ANAHEIM, CA 92807. 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 00 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 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. Poe. 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 "employee" 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. A& 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. NR` 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. t66 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.colb.ce.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: 6435 E SHADY VALLEY CITY OF ANAHEIM BUILDING DIVISION Permit Number. OLD2023-02461 200 S. ANANEIsi BLVD. Issued: 05118/2023 (714) 765.5153 www.enaheim.netlbuilding (714)7654628 Quarter Section: 205 Permit Number. BLD20n-02481 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 govem 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 stews 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 owners 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 owners signature. 7 1 ;Pr`ope ens Signature Date: