124 S MARTIN RD (2) Permit Types
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Permit Number: BLD2013-04653 -01.4
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(714)765-4626 200 sANAiEiM%BLVD.
Quarter Section:202 (714)765-5153
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i•:•"Legal Description it?B 242 IPG 48 PEAR 2 a 5 t o a a ` w,
OWNER-BUILDER DECLARATION:
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 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 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
7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).
I,as owner of property,or my employees with wages as their sole compensation,will do( )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 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).
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V/ 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 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.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: htto//wwwieginfo.ca.o,ovicalaw.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 purposes.
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 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: Policy No.: Expiration Date:
JName 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 Califomia,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.
Signature of Applicant Date
Permit Number: BLD2013-04653
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I he?Ly af*rriunder penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued
(Stc. 097.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 the
Business and Professions Code,and my license is in full force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE(S)
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.
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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: - }��''?
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An application for a building permit haskbteen submlt�eldi h� yoour:riamejllisting,yourself as the builder of the
property improvements specified�at �' J 1 \,�i },' ,I , p f,E 1 �.J�. S 9Lgcg
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We are providing l\\ ' ?0 �' j l I N, p l i f 1� 1� r i
you with an�Owner-Build,er Acknowl_edgment�and Iriformatfon�Verification Form to make
you aware of your responsibility Viand'posslbl•ensy..ou,maycur b�y having,th�permit issued in your
name as the Owner-Builder, ;s�r.
We will not issue a building permit until you haue(read;initial;e.d your understanding of each provision,
signed, and returned this form to us at our offici'alta'dd_ress$ii dicated. An agent of the owner cannot
execute this notice unless you, the property owner ibta i.,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.
SV 1. 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.
SV 2. I 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.
SV 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.
,cV 4. I understand Contractors are required by-law to be licensed and bonded in California and to list
their license numbers on permits and contracts.
5. 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.
6. 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' 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.
MARCH 2009
200 S.Anaheim Blvd.,Suite 145 Anaheim,California 92805 (714)765-5153 Phone (714)765-4607 Fax www.anaheim.net/building B72 1