216 S. West St. (2)
APPLICANT: VICTOR HIPOLITO
OWNER INFORMATION: CONTRACTOR INFORMATION: ARCHITECT/ENGINEER INFORMATION:
Irma Sandoval
216 S West St
Anaheim, CA 92805
JOB DESCRIPTIONlnstallalion of a 9'x11' patio enclosure (ICBO 3190-P) and new 4'x4' widow for emergency egress.
,
VALUATION: 5,500.00 PROCESSED BY: DOR
I OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor"s License Law for the following reason (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 such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9}(commencing with Section 7000 of Division 3 of the Business and ProfessiimsCode) or that he is exempt therefrom and the basis for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit sUb/ects the applicant to a civil penalty of not more than five hundred dollars
~500). . .
LJ I, as owner of property, or my employees with wages as their sole com~nsation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044. Business andProfessions Code: The Contractor's License law does not apply to an owner of property who builds or improves
thereon, and who does such work, himself or herself or through his or her own employees, provided that such improvements are not intended or
offered for sale. If, however,the building or improvement is sold with one yeilr of completion, the owner-builder will have the burden of proving that he
did not build or improve for the purpose of sale).
o I,' as the owner of the property, am exdusively contracting with licensed contractors to construct the project (Sec. ,7044 Business and Professions
Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with
FLqontractor(s) licensed pursuant to the Contractor's License Law).
U I am exempt under Sec. , B & P.C. for this reason:
Date: Owner:
WORKER'S CO PENSATION DECLARATION
I hereby affirm under penalty of pe~ury one of the following declarations:
o ) have and will maintain a certificate of consent to self-insure for worker's compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for whidl
this permit is issued. '
'Jv( I have and will maintain worker's compensation insurance, as required by Section 3700 of
~Labor Code, for the performance of the work for which this permit is issued. Myworker's
Compenpayon insurpnce carlier and p,2li,CY are: ~
carrier:V;t2(J/nHi Ol/ieETV P Policy Number. CXJ->-<q:>Oi CJZ(/ U
This section need not be completed if the pennit is for one hundred dollars ($100) or less.
o I certify that in the perfonnanceofthe work for which this permit is issue~, 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 su ct to the wo er'-s co pensation
provisions of Section 3700 of the Labor ad ,I If forthwith c mply' ~hose provisions.
BUILDING PERMIT NO. BLD2004-03179
TYPE OF PERMIT
Patio Cover
DATE: 8/18/2004
JOB ADDRESS: 216 S WEST ST
LEGAL DESCRIPTION: WEST BROADWAY TR LOT 13 BLK2 NLY
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765.5153
INSPECTION REQUESTlINE:
(714) 765 - 4626
CENSUS CODE: 434
QUARTER SECTION: 63
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am
licensed under provisions of chapter 9 (commencing
with Section 7000) of Divs' n 3 oft usiness'and
Profession Cod .
8/18/2004
Date:
NUMBER
TYPE
Construcion Types:
VN, ,
Fire Sprinklered?
Patio Area:
Date: 8/18/2004 Applicant:
WARNING: FAILURE TO SECURE R R'S COMPENSAT N VERAGE IS
UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRI INAl PENALTIES AND CIVIL
FINES UP TO ONE HUNDRED lHOLISAND DOLLARS ($100,00Qh IN.AoDITION TO THE
COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN' SECTION .3706 OF THE
LABOR CODE, INTEREST AND ATTORNEY'S FEES.
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 Information: '
!--.
I certify that I have read this application and tate that the above information is correct. I
agree to oomply with all city ordinanceS . 'state laws relating to building construction, and
hereby authorize representives of ttiis to enter upon the above mentioned property for
insp . '/ r~ // .
L/ ~ v. Date: 8/18/2004
Signat App i98nt or Agent
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.
EXPIRATION DATE
NO
99
Fees paid for Pennit:
Total:
535.36
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