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1419 N PARKHAVEN DR (3)Permit Types BLD I ELE MEC PLM X Permit Number: BLD'923-00584 Issuer±: 02/03/2023 4 www.anaheim.netlbuilding (714)765-4626 Quarter Section: 16 CITY OF ANAHEIM Site Address: 1419 N PARKHAVEN DR, Anaheim, CA 92801 Legal Description: N TR 7658 BLK LOT 16 APN:07074428 OWNER - BUILDER DECLARATION: BUILDING DIVISION 200 S. ANAHEIM BLVD. 1714) 765 - 5153 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's License State Law for the following mason(s) Indicated below by the checkmark(s) I have placed next to the applicable Items) (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 1 licant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). as owner of property, or my employees with wages as their sole compensation, will do 1_) all or ( 11 portions of the work, and the structure is not Intended or offered for safe (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). 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 appy 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 1 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. 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: http://www.lecinfo.ca.aov/colaw.html. By my signature below, I certify to each of the following: I am the property owner or autho ' t act the property owner's behalf. I have read this application a he' o n I have provided is correct. I agree to comply with I h e ci d county ordinances and state laws relating to building construction 1 authorize represen�v of is ci r county to enter the above identBed property for inspection purposes. 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 self -Insure 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: 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 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, l shall forthwith comply with those provisions. 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 (S) - y m CITY OF ANAHEIM BUILDING DIVISION Permit Number: BLD3-00584 200 S. ANAHEIM BLVD. Issued: 02/03/2023 17141765.5153 www.anaheim.net/building (714)7654626 Quarter Section: 16 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 1419 N PARKHAVEN DR. Anaheim, CA 92801. 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. nderstand 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. understand building permits are not required to be signed by property owners unless they are responsible for the nstruction and are not hiring a licensed Contractor to assume this responsibility. 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 risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. G�4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on P--�rmits and contracts. 5. 1understand 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. kc• I 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 ,e7. I 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. �j8.1 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 work anship 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 Califomia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. 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: 1419 N PARKHAVEN Permit Number: BLD2023-00584 Issued: 02/03/2023 www.anaheim.net/building (714)765-0626 Quarter Section: 16 Pe It Number: BL02023-00584 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. eel 2.1 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 theRermj>t!' CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 5153 Note: A copy of the property ees ees license, form notarization, or other verification acceptable to the agency is required. to be presented when the is 1 ued to verify the property owners signature. Pro wners'S1gnature Date: Q: r CITY OF ANAHEIM RECEIVED PLANNING DEPARTMENT FEB 0 2 2023 BUILDING DIVISION ���� ��yy��CITYgO�F ANAHEIM AUTHORIZATION OF AGENT TO ACT ON BEHALF OF PROPERT'1r'VWNjk FORKNG DEPARTMENT `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. New ownership for Permit #BLD2015-06827 Project Location or Address: 108 N Tustin Ave, Anaheim, CA 92807 Name of Authorized Agent: Breeanna Martinez Address of Authorized Agent: 1249 S Diamond Bar Blvd, Diamond Bar, CA 91765 Phone Number of Authorized Agent: 714) 726-4995 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 Bill I declare under penalty of pedury that I am the property owner for the address listed above and I personally filled out the above infrmat* and certify its accuracy. Property Owner's Office Use Only: ID Verified Ownership Verified Documents G�'� Planning Info Permit # Ak;P2-o/5 -yL X 21 /DuDLp1,3 -v DS -7 3 1/3012023 200 S. Anaheim Blvd., Suite 145 Anaheim, California 82805 (714)785.6153 Phone (714)7854607 Fax OCT 2013 www.anaheim.netlbullding B720 CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION OWNER43UILDER 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 108 N Tustin Ave, Anaheim, CA 92807 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. F0 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 acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. ,f 0 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. O3.1 understand as an "Owner -Builder" I am the responsible. party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. PO 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. F0 5.1 understand if I employ or otherwise engage any persons. other than Callfomia 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. PO 6.1 understand if I am considered 'an "employer under state and federal law, I must register with ' MARCH Zoog 200 S. Mahaim 13W., Sults 145 Anaheim, California 82805 (714)765,5153 Phone (714)766-4607 Fax 6721 .L. .sM1..11J7� `the state and federal government, 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. _ LO7. I 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. Po 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. t V 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. PO 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: 10t N TL41rhn .Av,& Pthm6,m.W,fo —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. D 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 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 property 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 Signature: PAGE 2OF2 200 S. Anaheim Blvd., Sub 145 Anaheim, California 82805 (714)765-5153 Phone (714)7654607 Fax --.a .. B72� _�_:_ na:--