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Box 1768 1 Newport Beach, CA 92658-8915 wnw.rewoarbeachca.acv 1(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 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 DIRECTIONS. Read and initial each statement below to signify you understand or verify this information. D, 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, 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 acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. ID1,2. I 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. Q,3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that 1 may protect myself from potential financial risk by hiring a licensed Contractor and ha ving the permit filed in his or her name instead of my own. W 4. 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 Contractors, 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. V/ 6. 1 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 compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. DL -7. 1 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 aft 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. 1 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. LA—e9-1 understand I may obtain more information regarding my obligations as an employer" from the Interna! Revenue Service the United States -Small Bus; Ad,,,,,, tr2t,..�,, the rat v,�,�a nep^artment of Benefit Payments, and the (`arifCmia Division of industrial Accidents. 1 also understand I may contact the alifomiaContractors' State License Board (CSLB') at 1 -800 -321 -CSL R (97�9) or N rr.�,lb.ca.gov fcr more information about licensed contractors. &10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the parry legally and financially responsible for proposed construction activity at the following address: .t� .1 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. 12. 1 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. Ucensed contractors are regulated by laws designed to protect 9 9 p..,t .,� the public. if you contract with someone who does not have a license, the Contractors' State License Board may be unable to asget 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 smpicyee of ftt Indh:,dual or firm Isn ured while working g P+i your property, you maybe 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 properly 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:, Property Owner's Signature:_Ziw Jl Date: 3 3 f Note: The-fnlinwinn dnfhnri�sti., C!- AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which 1 understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(5) 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 Agent: Tel No 1 declare under penalty of perjury that 1 am the property owner for the address listed above and I Personally filled out the above information and certify its accuracy. Mote. A copy or the owner's dryers icense, form notar,'zador,, or othe;,r verfication acceptable to the agency is required to be presented when the permit is issued to vert l the property owner's signature. Propery Owners Signature: Date: N0'8.: r h - 1pf er s jrl r--r'c ican e or fpr"` otq-H--s-!or .5 real(r ti r_. !Le r eser!ted 4Vhe" '.he _ _