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J JJ c SdtN E �o mW mw E Eca 0nt►o.w 3 '- O m m imo. woaad M do,c `t oa Vw z wo 3.y n O ¢EEU mo ow 2 zLa -ZVU0 c Ha VUWa Z W & N ic QN m ~mCET' aN°a w O' Sze WO46 N EiRO LL, 0 c LO pNj OE= u P�m" 2Qa• 0 L C m m M w ao -nNLd - rO� MWN❑E O Wao~uN =-•a �• y Q 13Lm p0 pCf 0 f Cf CC CO 0 O G C O f P CC O C G C C C p0 b N T O O O E Of! ffC` fC`f CE 9 Opp )(z011Is ,�r 14139 94lQar is w,, CC P pC p C f P O 4 T 0 E m E CI`T.N' 'NEWPORT BEACH �) COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION j (949) 644-3200 NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at iyJ� fJll�4P7°A A/EWIx'�T i GN CA 3E!n . We are providing you with an Owner -Builder Acknowledgment 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. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION D TIONS Read and initial each statement below to signify you understand or verify this information. 1. understand a frequent practice of unlicensed persons is to have the property owner obtain an Ow r -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 homeowners 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 my erty- understand 2 uunderstand 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. rAO 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. 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 1 employ or otherwise engage any persons, other than California licensed Con ctors, 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. 91& 1 understand if 1 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." 1 also understand my failure to abide b these laws may subject me to serious financial risk. I understand under California Contractors' State License Law, an Owner -Builder who builds sin 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. 6 understand as an Owner -Builder if I sell the property for which this permit is issued, i may be hel able for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction: defects in the workmanship or materials. 1 _ 'ea� understand i may obtain more information re • ••,, • • • internal rR--.ver a man✓ t r gar;ltmo Loy oifta'+rg aG Br• � F0- Q� •o..r v E ii _ SCE. tme ilnitar+ Cf�ges C^,at. j,�sireS3 Ad— � � t,.ee. �� ver«"v'ri3a iJepaa uereiei-�"'Frr Benefit PaV.meniS, and fh9 --ifal ;la 'riivisioi, of industrial Accidents. i also understand! may contact the Calif-orn; Cvn actvr3' $tale License Board {C$ a§,t ore information about licenser! Cnntrrct.,.- — 7ca am aware of and consent to an Owner -Builder building permit applied far in My name, arc understand that f am the . arty legally and flnancialEy resp nsible for proposed construction, activity following address: / /�j� }� fA ����Pr� w � ��© Y ai the f agree fhat, as he party legally and financially responsible for this proposed construction ac -ti . , 1 will abide by alt applicable laws and requirements that gcvsm Omer -Builders as well as em foyers. 2_ I agree to notify the issuer of this form. immediately of any additions, deletions, or change to anI a lmoratior, f have provided on this form. icer:sed contractors are regulated oy laws designed to protect the public. if you centras with someone wno does not have a license, the Contractors, State License Board may be unable to assist yntLi wit any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in .,ivii court 4 is also. important for you to understand that if an unlicensed Contractor or employee of that individual or firer, 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 (heir workers' compensation insurance coverage. Before a building permit can be issued, If s form must be c ; pleted area signed by time property owner and returned to the City oe Newpoe i Beach, Building Division, for issuing the permit_ note. A copy cf free property owner's drover's license or form notarization is required to he Presented when the permit is issued to verify the property Owner's signature. Print name of property owner -_7000 L-'Aii/V r_-�'— i Property Owners Signature: ewe /jp o F Da#'_ 1 7 _2217 ('7 AUTHORIZATION OF AGENT TO AOT 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(sl to act as my agents; to apply for, sign. and file the documents necessary to obtain an Owner -Builder Permit for my project. Sccpe of Construction Project (or Description of Wolk,: Project Location or Address: Name of Authorized Agent: Address of Authorized .A.gent: Tai rjc� declare + r dsr penalty sof ce,iury that iam the pr'JpEftj OttttP,Er for ii':E address listed abGti3 ai*G_ parsorallys filed out to above :rfCrm. ,eLor and certify its acC r-C..."lore zi �"- - C!'th,E C'Ntiet's '.Ir i/E a rCe SE, Oiar or (2 Je Ca%Cr aCCe ta'ufe ;-, he 3gerlqll is 'eGu%reGO JE fESa Ced HVttS, :he Ce, r,-& rS ssue:{ tC ire (f if!g ,JrOpeT y 3� rg S 3:g1?a lire. S pj .. • .... • •....Y Y �..-•. 1 _ 'ea� understand i may obtain more information re • ••,, • • • internal rR--.ver a man✓ t r gar;ltmo Loy oifta'+rg aG Br• � F0- Q� •o..r v E ii _ SCE. tme ilnitar+ Cf�ges C^,at. j,�sireS3 Ad— � � t,.ee. �� ver«"v'ri3a iJepaa uereiei-�"'Frr Benefit PaV.meniS, and fh9 --ifal ;la 'riivisioi, of industrial Accidents. i also understand! may contact the Calif-orn; Cvn actvr3' $tale License Board {C$ a§,t ore information about licenser! Cnntrrct.,.- — 7ca am aware of and consent to an Owner -Builder building permit applied far in My name, arc understand that f am the . arty legally and flnancialEy resp nsible for proposed construction, activity following address: / /�j� }� fA ����Pr� w � ��© Y ai the f agree fhat, as he party legally and financially responsible for this proposed construction ac -ti . , 1 will abide by alt applicable laws and requirements that gcvsm Omer -Builders as well as em foyers. 2_ I agree to notify the issuer of this form. immediately of any additions, deletions, or change to anI a lmoratior, f have provided on this form. icer:sed contractors are regulated oy laws designed to protect the public. if you centras with someone wno does not have a license, the Contractors, State License Board may be unable to assist yntLi wit any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in .,ivii court 4 is also. important for you to understand that if an unlicensed Contractor or employee of that individual or firer, 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 (heir workers' compensation insurance coverage. Before a building permit can be issued, If s form must be c ; pleted area signed by time property owner and returned to the City oe Newpoe i Beach, Building Division, for issuing the permit_ note. A copy cf free property owner's drover's license or form notarization is required to he Presented when the permit is issued to verify the property Owner's signature. Print name of property owner -_7000 L-'Aii/V r_-�'— i Property Owners Signature: ewe /jp o F Da#'_ 1 7 _2217 ('7 AUTHORIZATION OF AGENT TO AOT 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(sl to act as my agents; to apply for, sign. and file the documents necessary to obtain an Owner -Builder Permit for my project. Sccpe of Construction Project (or Description of Wolk,: Project Location or Address: Name of Authorized Agent: Address of Authorized .A.gent: Tai rjc� declare + r dsr penalty sof ce,iury that iam the pr'JpEftj OttttP,Er for ii':E address listed abGti3 ai*G_ parsorallys filed out to above :rfCrm. ,eLor and certify its acC r-C..."lore zi �"- - C!'th,E C'Ntiet's '.Ir i/E a rCe SE, Oiar or (2 Je Ca%Cr aCCe ta'ufe ;-, he 3gerlqll is 'eGu%reGO JE fESa Ced HVttS, :he Ce, r,-& rS ssue:{ tC ire (f if!g ,JrOpeT y 3� rg S 3:g1?a lire. S pj CITY OF NEWPORT BEACH COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915 www.newportbeachea.gov 1 (949) 644-3200 SMOKE DETECTOR AND CARBON MONOXIDE SELF -CERTIFICATION (this certification is to be filled out by the permittee or homeowner) Project Address: } 1 �`6 11 } �' a: W f�-y Permit Number: X ao l ,4 _1326C Property Owner: Ri� fw A- E42g> c)1t % X Vic - Licensed Contractor: Lic #: XZOt7-s37� �d938 N;ioria Way The State of California now requires that smoke and carbon monoxide detectors must be installed in all residential buildings California Residential Code (CRC) Section R314.1, CRC R315.2 states in part that existing dwellings be "retrofitted with smoke detectors and carbon monoxide detectors. CRC Section R314.3, CRC R315.3 defines required locations. Both boxes below must be checked: 5do Carbon Monoxide Alarm: On the ceiling or wall outside of each separate sleeping area in the immediate vicinity of bedrooms or in each hallway outside of the rooms, and each level of the dwelling. Detectors are also required in ,,.f bedrooms with gas fired appliances lb r Smoke Alarms: Installed in each room used for sleeping purposes, outside each sleeping area, and on each level of the dwelling unit. Retrofitted detectors may be battery operated for buildings where no alterations are performed on the interior. Multiple -purpose alarms (carbon monoxide and smoke alarms) shall comply with all applicable standards and must be approved by the State Fire Marshall. The devices must be installed per manufacturer's specifications. 1, the undersigned, hereby certify that 1 am the permittee or homeowner of the project. I further certify that smoke alarms and carbon monoxide alarms are present and tested to be functio I in al following locations: Signature: Date: i2-tF-ix NOTE: This self -certification is only used for projects to the exterior of the structure where access to the interior of the dwelling by the City of Newport Beach Building Inspector is not achieved during the course of construction. Forma\SmokeDetectomndCarbonMonoxideSel(Cert 05/12116