HomeMy WebLinkAbout104103093 - PermitCity of Santa Ana 20 civic Center Plaza (M-19), Santa Ana, CA 92702 Building
Permit Counter: (714) 647-5800 lnspection Requests: (714\ 667-2738 lnspector Section: (714) 647-5853
Permit #: {O4tO3O93
Pin #: 854sii
Assessor's Parcel:410-381-03 Lot: NA
Bldg: Address Range:Suite Range:
Zoning: M1Block: NA
Building Use:
Job Type:
Nature of Work:
Exasting Bldg. & Use
Proposed Use:
lndustrial
Tenant lmprovement
N/V - Bathroom
lndustrial
B
VB
cBc 2019
x-0602320278J
1st FL Area:
2nd FL Area:
Other Areas:
Garage Area
Total:
Patio:
T.l.Area:
Yards Req'd:
Valuation: $1,500.00
Description of Work: Remove unpermitted bathroom facility and restore back to point of origin
Planning Conditions:
Engineer
Address.
6FtiE r rfltIHG
Owner:
Address
Phone:
Tenanl:
GENE L FELLING
2220 S LOARA ST
Anaheim, CA 928023914
(7',t4177s-7735
Owner-Builder
Phone:
State Lic #:
Lic Type:
Bus. Lic #:
Workers' Compensation lnsurance
Carrier:
Policy #:
Expires:
Gener0l ['l cn Uptlote F
nl 116002- 5l6110rlrl[-
P,u i 1d ing
ul116r-102- 51601000-
Blds Stds Revolv in e
01 116r:ltr2- 516t2r10r1-
llicrof ilr & Doculents
0t t t,4ll0?- 5777ttDttD-
V i!.o
CC+ : Ix*r*rr*r r*x961'9
Phone:
License #:
Architect /
Designer:
Address;
Phone:
License #:
Planning Approval By:
Plan Checked By:
Permit lssued By:
NPDES lnsp. Req'd:
PWA lnsp. Req'd:
Planning lnsp. Req'd:
Landscaping lnsp. Req'd
Graham, Jeffery
Chavez, Da
Dale. 02/l'112020
Dale:
Dale 0211112020
Subject to Field:
Nrisc. Receipt
l\ilisc. Receipt
NIisc. Receipt
No
No
No
No
*oo'
0 77760 0 2
07776002
0 77 7600 2
0 77760 0 2
07776002
0 77 7600 2
0 77760 0 2
5760 7
57770
5760 7
5760 7
57672
s7600
5760 7
$166.53
$3.91
$100.57
$252.69
$1.00
$22.95
$s7 .20
No
No Account#
Permit Fee
Microfilm Records
lnvestigation
Penalty
Bldg Stds. Revolving
General Plan Update
lssuance
Fire lnsp. Req'd:
Police lnsp. Req'd
Flood Zone Cerl. Req'd: No
Every permit issued shall become invalid unless the work on lhe site aulhonzed by
such parmit iscommenced withtn 360 days aftet its issuance.or il the wofu authorized
on the sile by such pemit is suspended ot abandoned fot a period of 360 daysafter
the time the work is commenced
$604 85
$0.00
$604.85
MID#: 2020-157688
01 1 16002 51600
011't6002 51601
01 1 16002 51612
01116002 57770
$22.95
$576.99
$1.00
$3.91
Project Address: 2434 S Broadwav Unit:
Tract: NA Historicr No
Occupancy:
Constr Type:
Code:
Flood Zone:
# of Stories:
Bstchi:54335 - 2/ll/2t1?0 l0r qnorol
office: CTYI'I Trftns+! 121 1 ol
A,:ctf : Rel+: 10(1r:liiL'l?J
firl,t+: (t?89?tr,l7 - 2/ll/?ttz(t l?357 Pll
Tronsoct ion Totql l97t:t. {g
Contraclor:
Address:
iii76, 99
t1 , t[r
19?0. ig
AuLhi i|li].i7
Fee Total:
Paid to Date:
Balance Due:
Total
lnspector
BUILDING. INSPECTOR RECORD
SITE.WORK DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
I hr€hy alfirm und6 p.nalrr ol tEjury rhd I an.r.mpl torn th€ ContracloE l-ic.@ Liw aor rh. lollowinS ree. (s(.?011.5
ausirGs md ftofGion Codc): Any Cily or County s'hich r.qut6 a Fmit ro coNrucl. ahs. imprcvc, &nolish or rQan uy
(rudu.. riorro ils isudcc. also r.quiB rh. appli.anl for luch pmil lo lilc 0 sisncd slaldnol lhal h. or sh. i5 licmsl puulant
ro rh. provisioN ofthc Conlraclols Lic.nsed titr (Chaptd 9. Con.Eicing with Selion 7000 olDilision I oflh. Ausincs dld
PofsionsCodc)!rlhalhcorsh€iscr@prlh.ctorandihc6asisfortheaucs.dcrcmplion.Anyviolalionofs..rion?0ll5bytny
applica for !p6nil subjersrh. appli.am to acivilp.nahyofnot morclhe fiv. hu.drcd doll6 ($500).
I. s o$ ncr oflh€ FoFtry. or my €nployc w h wa!6 4
'hci
&1. .o6pdMtion. will do lh€ wort dd ln. $rucl@ is nul
mt6& orotrcEd for ele (Sc.7044. Bcins dd PmfNioB Cod€: Tne ConlEclois Lrtu.Irw do6 not tpplyto M owndof
lhe pmpoly sho hil6 o! imrrov6lh€mn. udvho do3 n(hqo hnns.llorh6dlorlhoushhisorhcro*n.mploy.6,
proridcd rhar such inpmlanm6 m nor intmded orofid.d lorel..li ho*od, lh building or inprovmat is eld wnnin onc yw
of compldion. th. O",.s Duildd will ha\r thc hudo olp(iving rhd h. or shc did mt l,rild or imFoir lh€ plopqly tut lh. p1iro* ol
-1,
6 oM6 ofln. FoFlr, m .r.lusi!.ly .onradtru *nh ricd.d contradoN to co.slolI rhc Fojd (sa 7014. &tso*
a.d Aoftshn codcr Th. CoDrrrclo.s Lic€se L.v do6 nor apply lo d o{nd of propdy wno builds or i prov6lh6on.
and who conlrrcrs lo. such Droj.ns vith a ConrEcto(s) licms.d pu6uMl to th. ConlElor's Li.ce kw).
(
DECIdIAIIO!
t h6cby affid undd psDlry fpdju.yon. ofrh. aollowin8 ddltralioN
I havc dd willm.inrain r cdincar. olcoBni to SclfJnsurc ior *orkqs coor!tuarion. d pbvidai for by Selion 1700 oflh.
tlbor Codc, foi lh. pffonnmcc oftn. wo' k aor wnich lE p6nxl is issued.
Ihav.andwillmaint.inNorkcrscomFnsalioniGuraocc.asr.qutibySErion1700otthcLaborCode,forthcpdromMc.of
rnc $orl for rhicn this Fon is isucd. My rdk6 conpoetion insu@cc cmi.r Md policy numbs d.:
I.diry$al in $c pdlotuc. oflh. *ork for $hi.h rhis pdmn is issu.d.Ishallnol dploy any p6en in an, n nr
s 6 ro b..o6. subjer !o lh. $o 6'comFN.lioD larsofCaliiodr!. dd age$d ial sbotrld bc.onE subJel lolh. .-M*d conpssrio. pmvilions of sdion l T00 oflt lihor Code l slall. fodh*nh conPly vith rt F pmvisio6
WARNINC: Failur. ro su. wort6 onp.6.rrion co!d8. is ulavtul. and slull subjsl & 4plorq ro riniml FEI6 md
cilil fin.s up ro on. hundred lhousd dolln ($100.000). i.
Srrion 1076 orrh. Lnbor Cod., inrffir &d,trotry's f6
DECBAAIION
I trftby amrm undq poalty of tEjury lhal I m li.dEol und.r Fovision olchaplg 9 (comdcins
of the Bsin6 d PofsioN Codc, d hy !i.ft. is in lull forc &dcffer
CONSTRUCTION LENDINC ACENCY
I h6eby lrm und6 pdalry of pd!ry rhd rh6. is . coNrruclior k dins asdcy for $c psfonm.c of th. *ort aor pnich lnis pdnit is
issu.d (Sd 3097. Civ C.)
ATPIICANI.DECI.ASA]IA!
I ndlby &fllm und6 p.n6hy of pqjuy on€ ofrh. aollosif,U delaralionsi
Danolition Pdmits-Asbcsros Norilic.tioo !-cd6ar Rcgulariod (Tillc 40. Pd16)
Requt d LardoiNoli6cation
I cdi& lhrt rh. fcdcral resulalions rcsudins 6b61ot Enoral dc .or .pplicabL ro tht poj.tl.
Crttn,',al I have Gd lhG aptli.arion and sr,r.rhat th..hov. inlonsalion is cord. I asrd ro conplywnh allcnyand Coury
Sratc InNs Elams ro buildins .oGttud io., .nd re!.66taliv6ofrhb Cny Md Cou,lyro sl6 urFn thc
abolc nc.iioned po!,^ny for i6pe-lon -il ^p
x-l--)st
Set Backs
Forms/Steel/Holdowns
Ereclion Pads
UFER Ground
SLAB Floor
Subf loor/VenUlnsulation
Roof Sheathing
Framing
ln s ulation/Ene rqV
Drywall
Ext./lnt. Lath
Brown Coat
Masonry
Pool Fence
T-Bar
Handicap Req
De U Final Re port
Engineer Final Report
Flood Zone Certif.
FINAL 1 tLla D/rm 61,-*5?
Certificate of Occupancy tu
Notes, Remarks, Etc
,,^,". c 1-JrAO
I-ic.nseclars: Lic€n$Nu'nba:
Contr..lo.i_
L..ddt Ad.lr6s:
Shear Wall
Planning & Building Agency
Building Safety Division
20 Civic Cente. Plaza
P.O. Box 1988 (M-19)
Santa Ana, CA 92702
(714) 647S800
www.santa-ana.org
aPP-13 CBC 2016
NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building per 7\rt6-
ha been s tl itted i ygur-n?mtq /1{)
e listin yourself as the builder of th e prope rty im ro ments
specified at t,)
We are providing you with an Owner-Builder Acknowledoment and lnformation Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your names 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 ACKNOWLEGMENT AND VERIFICATION OF INFORMATON
DIRECTIONS: Read and initial each statement below to signify you understand or veify this information., ts-++
kt ' 1 . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Builder" build-
ing permit that erroneously implies that the property owner is providing his or her own labor and material personally. l, 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 acling as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my prop-
erty.6l*
ZI-D. t 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.3t*t,- t--(a4 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.B?9
QlEq. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers
on permits and contracts.les
4lES. t 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
"employe/' under state and federal law.
&.e_*
I lLa. 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 com-
pensation of each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk.ffi a-
. 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 a//work is performed by ltcensed subcontrac-
tors and the number of structures does not exceed four within any calendar years, or all of the work is performed under contract
with a licensed general building Contractor.
,41 e
4/FA. , understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any finan-
cial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workman-
shjp or materials.
,Fn-c
2tfl ,understand I may obtain more information regarding my obligations as an "employed'from the lnternal Revenue Ser-
vice, the United States Small Business Administration, the California Department of Beneflt Payments, and the California Divi-
sion of lndustrial Accidents. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at 1-800-
321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors.
.dt e'
|thO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the
party I
d ress:
,4+
egally and flnanc on le for NS activity
3
ng 4)L
Zu---11.1 agree that, as the party legally and financially responsible for this proposed construction activity, lwill abide by all
apIticable laws and requirements that govern Owner-Builders as well as employers.
,Gs s_
Q_qhZ I 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. lf 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. lt 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. lf you obtain a permit as Owner-Builder and wish to hire Contactors, 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. A/ote;A coov of the DroDertv owner's driver's license.fo rm n ota nza-
ac able to the enc when the ermit is issued to
proDertv owner's siqnature.
l-f-7oSignature of Prope(y Owner
Print name of owner L t @L g2o? o9{
qa,,o L. ilt*r-Lo ab b r 7
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize
the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder
Permit for my project.
Scope of Construction Project (or Description of Work)
Project Location or Address Aq3q J. E€owtt"L*?-
Name of Authorized Agent
Address of Authorized Agent:)37q S B.oao(r,
Phone Number of Authorized Agent:-ttL/_ tqo_t71 (
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above
information and certify its accuracy.
Property Owner's Signature 7-T-to
p1nt Nameof own"r. 6cc hb-tlt
Note: A copy of the owner's driver's license, form notarization, or o ther ve fication acceptable to the agency is re-
quired to be presented when the permit is issued to verw the propertyr owner's signature.
Ka*Lke^ /J, . lr,lu L
q