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523 S CLEMENTINE ST (5)Permit Types BLD ELE MEC PLM fX X X Peimit Number:BLD2009-Q2054 Issued:06/29/2009 INSPECTION REQUEST LINE: (714)765 -4626 Quarter Section:84 Site Address:523 S CLEMENTINE ST Legal Descrii^lbmNTR 365 BLK B LOT2 BUILDING DIVISION 200 S.AN^EIM BLVD. (714)^65-5153 Project Description:Plumbing and Electrial to remodel bathroom and kitchen and upgrade service to 200amps.Work started prior to permit.REF BLD2009-01993 Valuation: Construcion Types: Total Fees paid for Permit: N/A,, 933.66 People Associated with Project: Owner TROY DANG 523 S CLEMENTINE ST ANAHEIM CA 92805-4619 Permit Applicant TROY DANG Electrical Fixtures Qty Type Ptumbing Fixtures Qty Type Mechanical iFxturesType Qty Receptacle,switches,lights Meter/Disc Sw -under 600 V,up to 200 amps 47 Shower 1 Lavatory Water Closet Kitchen Sink Repair/Drainage AlterationA/ent Piping Dishwasher Water Heater 1 Heating Appliances,including vent 1 Central Vacuum System 1 Heating/Cooling Coil 1 Residential Registers 1 Ventilation Fan -<=300 cfm on single duct 1 Gas System (1 -5 outlets) 1 1 1 8 2 1 1 The permit shall expire by limitation and become n ull and void if the building or work has not passed final inspectbn 365 days from the date of permit issuance.A new permit is required to commence or continue woik.fbid permit combo All applicable Items below must be signed before utilities will be released. FINAL INSPECTIONS DATE INSF^ECTOR Final Gas Test Building Division Electrical Final Plumbing Final Mechanical Final Cross Connection Control (714>765-4280 Engineering/Grading Final (714)765-512g Fire Dept.Final (714)765-5041 Fire Sprinkler Final (714)765-5041 Water Engineering (714)765-4591 Do not occupy this building until the final inspections have been made Sub List/Business License (714)765-5194BUILDINGPERMITDOESNOTAUTHORIZEELECTRICAL,PLUMBING.OR MECHANICAL INSTALLATIONS -SEPARATE PERMITS ARE REQUIRED.Zoning (714)765-5139 Building Final (Last Inspection - Only After Above Complete) INSPECTION DATE INSPECTOR Do not pour concrete until the following applicable items have been signed: Plumbing (Ground/Underfloor Drain Waste)FINAL INSPECTION must be approved by the Building Division. Electrical Ground Electrode/Ufer PARTIAL INSPECTIONS Setback/Forms/Trenches (Footings) Do not install subfloor or pour floor slab until the follwing applicable items have been signed:Building inspections Plumbing (Ground/Underfloor Water) Underfloor Rough Gas Mechanical (Groundwork) Electrical (Underground Conduit) Pre-slab (Compaction/Membrane Reinf.) Floor (Joist/Girders) Underfloor Insulation (Raised Foundation Only) 2nd Floor (Floor Nailing) Mechanical InspectionsDonotcoverorconcealtheworkbelowuntilthefollowingapplicableItemshave been signed: 1st Floor Shear Firesprinkler (Rough)(Fire Dept.) 2nd Floor Shear Roof (Sheathing/Diaphragm/Frame) Masonry (Reinf./Bond Beam/Pre-Grout) Rough Plumbing (Top Out) Rough Duct (Mechanical)i lV IPlumbingInspections rr^-^PiREDRoughMechanicalTWFTpRoughElectrical Framing (Only after PIbg.,Ele.,Mec.&Fire) Insulation (Sound/Energy) TDonottapeorplasteruntilthefollowingapplicableitemshavebeensigned:n ADrywall Drywall Penetrations (Ele.,Mec.&PIbg.) Interior Lath Exterior Lath Electrical InspectionsGENERALITEMS Electrical Service Meter Exterior Plaster (Brown Coat) T-Bar (Struct.,Ele.,or Mec.) Sewer Water Engineering Backflow (Testable Only) Water Service Permit Backs Master-2008.xls Permit Types BLD ELE MEC PLM X X Permit Number:BLD2009-02054 Issued:06/29/2009 CITY OF ANAHEIM INSPECTION REQUEST LINE: (714)765 -4626 Quarter Section:84 BUILDING DIVISION 200 S.ANAHEIM BLVD. (714)765 -5153 Site Address:523 S CLEMEMTINE ST Legal Description:N TR 365 BLK B LOT 2 OWNER -BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractor's License State Law forthe following reason(s)indicated below by thecheckmark(s)I have placed next tothe 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 licens^pursuant tothe provisions of the Contractors'State License Law Chapter 9 (commencing with Section 7000)of Division 3 of the Business andProf^ions Code)or that he or she is exempt from licensure andthe basis for the alleged exemption.Any^olation of Section 7031.5 by any applicant for apermtsubjectstheapplicanttoacivilpenaltyofnotmorethanfivehundreddollars(S500)./ I,as owner of property,or my employees with wages as their sole compensation,will do 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 Law does not apply to anownerofpropertywho,through employees'or personal efforts,builds or improves the property,provided that the improvements are not intendedorofferedforsale.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 apply to an owner of property who builds or improves thereon,and who contracts for the projects with a licensed Contractor pursuant to the Contractor's State License Law). I am exempt from licensure under the Contractors'State License Law for the following reason: By my signature below I ackonowledge that,except for my personal residence in which I must have resided for at least one year prior to completion oftheimprovementscoveredbythispermit,I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entiretybylicensedcontractors.I understand that a copy of the applicable law.Section 7044 of the Business and Professions Code,is available upon requestwhenthisapplicationissubmittedoratthefollowingWebsite:httD://www,leainfo-ca.Qov/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 owner's 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 relating to building construction I authorize representatives of this city or county to enter the above-identified property for inspection purpo^s./4\}a ef />1 /n ?Signature of Pn^pertylpwner 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 (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 self-insure 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: Name of Agent: 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,and agree that,if I should become subject to the worker's compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with those provisions. Policy No.:Expiration Date: Phone No.: / Signature of Apj^ant Date Permit Number:BLD2009-02054 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 peimrt is issued{Sec.3097.Civ.C): Lender's Name: Lender's Address; LICENSED CONTRACTORS 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 theBusinessandProfessionsCode,and my license is in full force and effect. Contractor Signature Date NUMBER EXPIRATION DATE LICENSE TYPE fSI The permit shall expire by limitation and become null and void if the building or work has not passed final inspection 365 days from the date of permit issuance.A new permit is required to commence or continue work, Ibid permit combo declare CITY OF ANAHEIMINSPECTIONREQUESTLINE: {714)765 -4626 Quarter Section:84 Permit Number:BLD2009-02054 Issued:06/29/2009 BUILDING DIVISION 200 S.ANAHEIM BLVD. (714)765 -5153 OWNER-BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION FORM Dear Properly Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the properly improvements specified at 523 S CLEMENTINE ST . 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. j_9-1.1 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 workers on my property. 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. 7 ^3.1 understand as an "Owner-Builder"I am the responsible party of record on the permit.I understand that I may protectmyselffrompotentialriskbyhiringalicensedContractorandhavingthepermitfiledinhisorhernameinsteadofmyown. 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 Caliifornia 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. 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.cslb.ca.gov for more information about licensed contractors. iQ 11 'll II TV tblcl_owner_builder_info_verif Permrt Number:BLD2009-02054 J_H 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 followino address:523 S CLEMENTINF ST. 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 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. 15 Property Own^Vsignature Date: / lhld_owner_builder_info verif