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1-100 UV(AVI gNd,
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.newportbeachca.aov 1 (949) 644-3200
OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION
(HSC 19825)
NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing ourself as the builder of
the property improvements specified at /� L , C C �C !ti �l
We are providing you with an Owner -Builder Acknowledgment and Informati6n 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
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
I understand a frequent practice of unlicensed persons is to have the property owner obtain an
ner-Builder" building permit that erroneously implies that the property owner is providing his or her
In 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
actlix as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
property.
2. I understand building permits are not required to be signed by property owners unless they are
risible for the construction and are not hiring a licensed Contractor to assume this responsibility.
. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I
rstand that I may protect myself from potential financial risk by hiring a licensed Contractor and
i the permit filed in his or her name instead of my own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list
r license numbers on permits and contracts.
. I understand if I employ or otherwise engage any persons, other than California licensed
tractors, and the total value of my construction is at least five hundred dollars ($500), including labor
aterials, I may be considered an "employer' under state and federal law.
. I understand if I am considered an "employer' under state and federal law, I must register with the
e and federal government, withhold payroll taxes, provide workers' compensation disability insurance,
a contribute to unemployment compensation for each "employee." I also understand my failure to abide
se laws may subject me to serious financial risk.
. I understand under California Contractors' State License Law, an Owner -Builder who builds
Ie -family residential structures cannot legally build them with the intent to offer them for sale, unless
a work is performed by licensed subcontractors and- the trwmbefoof+ciructwrees dues not exceed four
wit in any calendar year, or all of the work is performgd ur,,6.'With with aolice4sed general building
q
ctor. pp pp : q
p p O q q
I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be
able for any financial or personal injuries sustained byearzy s6ibsequent ovin,Qr(s) that result from any
construction defects in the workmanship or matenal�s.
2 C Of P q
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Forms\owner builder verirdoe 08/12/16 1 of 2
4I understand I may obtain more information regarding my obligations as an "employer' from the
nen'refit al Revenue Service, the United States Small Business Administration, the California Department of
Payments, and the California Division of Industrial Accidents. I also understand I may contact the
California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for
l information about licensed contractors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and
rstand that I am the party legally and fins gially responsible fo,( proposed ppnstruction activity at the
Jnaaddress: 17MD �_c�ro" 11.4. /�i�4- X"W1 /W- WiYGI /
agree that, as the party legally and financially responsible for this proposed construction
will abide by all applicable laws and requirements that govern Owner -Builders as well as
Wf /Y 1 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to
n of the information I have provided on this form.
Licensed contractors are regulated by laws designed to protect the public. If 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. It 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. 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 City of Newport Beach, Building Division, for issuing the permit.
Note: A copy of the property owner's driver's license or form notarization is required to be
presented when the permit is issued to verify the property owner's signature.
Print name of property owner:
Note: The following Authorization Form is required to be completed by the property owner only
when designating an agent of the property owner to apply for a construction permit for the
Owner -Builder.
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
Name of Authorized Agent:
Address of Authorized Ager
I declare under penalty of pe
personally filled out the above
license, form notartWion= or of
the permit is issued o'velify K
Property Owner's Signatule: J
Note: A copy of the
permit is issued to �
that I am the property owner for the address listed above and I
nation and certify its accuracy. Note: A copy of the owner's driver's
r, ation ajc4ptableso t_4e agency is required to be presented when
Date: �j'� 4
I. ..• of —
AerAsS or form notarization is required to be presented when the
owner's sarsature.
. . ...
Forms\owner builder veriidoc 08/12/16 2 of 2