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1640 E LINCOLN AVE (3)Permit Types BLD_ ELE MEC PLM X Permit Number: BLD2023-01807 Issued: 04/18/2023 www.anaheim.net/building (714)765-4626 Quarter Section: 103 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714)765-5153 Site Address: 1640 E LINCOLN AVE, ANAHEIM, CA 92805 Legal Description: A TR ANAHEIM EXT BLK LOT 10 ANAHEIM EXT LOT 10 NLY APN: 03720142 OWNER - BUILDER DECLARATION: 1 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 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 appliicc���ant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). _ 1 I, as owner of property, or my employees with wages as their sole compensation, will do () all or LJ portions of the work, and the structure Is not Intended or v 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). 1, as the owner of the property, em exclusively contracting with licensed Contractors to construct the project (Sec. 7044 Business and Professions Code: The Contractors' State License Lew 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 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, 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./Avww.lealnfo.co.aov/caiaw.html. By my signature below, I certify to each of the following: I am the property owner or authorized to act 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 laws relating to building construction I authorize representatives of this city or county to enter the above -Identified property for inspection purposes. Dy l8Z-Z gnature 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 ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OR THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to selfinsure for worker's compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain worker's compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers Compensation insurance carrier and policy are: Cartier. Policy No.: Expiration Date: Name of Agent: Phone No.: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature of Applicant Date DECLARATION REGARDING CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued ' (Sec.3097.Civ.C): Lender's Name: Lender's Address: LICENSED CONTRACTOR'S DECLARATION: I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Contractor Signature Date NUMBER' EXPIRATION DATE LICENSE TYPE (Sl CITE of ANAhlEipa ;► PLANNING DEPARTMENT BUILDING DIVISION OWN_ � Ou. DER &WOWLEDGMEAfi' AND INF®RMAT ON VEamcATI N �'®Rf�l an.. 'tier California .$Attie" l=aw, if you,1110 properly ©rmar, tv 11 I)t1 rdrilb►fl to r�ur rifllec lt� gat � narnlil; t,:a t�iil previ►1Q You with tills fol -M Viii l) y4mr.a►iiV6. If yoir nra ; A _.♦ • •the state and federal government, withhold payroll taxes, provid8 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. . I understand under California Contractor' State License Law, an Owner Bullder who bullds s note famlly residentlai 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. I 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. . I understand I may obtain more Inforrnadon regarding my obligations as an "employer' from the Internal Revenue Service, the United States Small Business Administration, the Calrforrria Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand 1 may contact the California Contractors' State License Board (CSLB) at 9.800.329-CSLB (2752) or www.Cslb.ca.gov for more information about licensed contractors. i � 90.1 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: ILMI11. 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 em ployers. 92.1 agree to notify the Issuer of this form immediately of any additlons,'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 contractwith 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 uniloensed 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 owners driver's license, form notarization, or other verfiicatlon acceptable to the agency is required to be pr6sented wh�per It Is issued to verity the property owners signature. Property Owner'ri Signature; 1 Date: �23 I .. 200 5. M9halm Aird., $uJa 145 Mahaim. Cn11Fom1a02805 (714)705.5153 Fhono (114)7054007 Fax pacesoFs®729 ..4.l. ...4.AWb.