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X2®20 -31'� 11
26�°�
CITY OF NEWPORT BEACH
(.'ONINIi1NI'I'1' I)E%,' .LOPh1ENT DEPARTMENT
RIIILDING DIVISION
100 Civic (;enter Drive I p 0 Box 17681 Newport reach, CA 82658-6915
www.nuwoortbeachca day 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 m your name listing Wurself as the builder of
the property improvements specified at 2/ 6 s l/? S i-,E-1J2/!Z/3 . A, 1 PI:
We are providing you with an OwrenBudder Acknawledgment arA 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 OwnenBuilder
We will not issue a building permit until you have read, initiated 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
IREC MONS React and India! each statement be!niy to s,+ynify you a n7e star f or venfy this intortnatton.
I understand a frequent practice of unlicensed persons is to have the property owner obtain an
wner-Builder' budding permit that erroneously implies that the property owner is providing tits or tie,
awn labor and material personally. t. 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 properly My homeowner's insufance may not provide coverage for those injuries 1 am willfully
acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
oil my property.
2 1 understand building permits are not required to be signed by property owners unless they are
sfxnnsrhkr for the construction and are not hiring a licensed Contractor to assume this responsibility
3 1 understand as an 'Owner -Builder' I am the responsible party of record on the permit. I
kdhang
erstand that I may protect myself from potential financial risk by hiring a licensed Contractor and
d the permit filed in his or her name instead of my own
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list
e eV
license numbers on permits and contracts.
5, 1 understand If I employ or otherwise engage any persons, other than California licensed
onnaetors, and the total value of my construction is at Wast five hundred dollars (5500}, including labor
rid materials I may be considered an 'employer under state and federal law
_6. 1 understand if I am considered an -employer' under state and federal law I must register with the
ate and federal government, withhold payroll taxes, provide workers' compensation disability insurance.
nd contribute to unemployment compensation for each 'enployee.' I also understand my failure to abide
y these laws may subject me to serious financial risk
s nle7 I understand under California Contractors State License Law, an Owner -Builder who builds
-family residential structures cannot legally build them with the intent to offer thein toe sale, unless
aN 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
4ontractor
8 1 understand as an Owner -Builder d I sell the property for which this permit is Issued, I may be
tle l+able for any financial or personal inluries sustained by any subsequent owneir(sj that result from any
latent construction defects in the vvorkmanskt ororhfiitenats. a o
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