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0101_- - MI -i-
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
(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 Owns Builder Acknowledgment and Information Verification Forth 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 neach
provision, signed, and returned this form to us at our official address indicated. An agent of the t
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
MCTIONS. Read and iniBal each statement below to signify you understand or verify this information.
1. I 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. 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
acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
o y property.
_yJ2. 1 understand building permits are not required to be signed by property owners unless they are
re onsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
13. I understand as an "Owner -Builder" I am the responsible party of record on the permit. 1
understand that I may protect myself from potential financial risk by hiring a licensed Contractor and
he fining the permit filed in his or her name instead of my own.
U 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.
1 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
a materials, 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
site 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
bA ese laws may subject me to serious financial risk.
,. 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
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
SC traC tractor.
. I 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.
_9 understand ' may obtain more information regardino my obiigatttcnz as ar i �e roe e
;nter ae lapvP P jai, rira the United Staicc Cm?!! Pu_icirxe53 Ad—,* . ...-�iur ui; v
Benefit AavmeRis and the Calw--ia D:` s e_ ••,••:'•` a atE!vr: ,, a Department ui
'!slpir — Industrial Accidents. I also undefstandf Irmay Contact the
Califpmia C= i'I'Mc-Mrs' State 'License Board (CSi-B) a 1-Rn(7_S21-C-Si R �_J75Gj . �bra info, ation about licensed contractors.
T710. 1 am aware of and consent to an Owner uilder building permit applied for in my name: and
understand ittat 1 am the e 11 nd fir : iai y responsible for proposed construction activity
Y at the
ing address:
t i. I agree that; as he party legally and financially responsible for this proposed construction
activity, 1 will abide by all applicable laws and requirements that govem Owner -Builders as well as
eynyloyar5.
f 12. agree to notify the issuer of this form immediately of any additions, deletions, or changes to
an e lnfornation ! have provided on this form.
Cansed contractors are regulated by laws designed to protect the public. If YOU contract wish someone
who does not have a license, the Contractors' State License Board may be i_nabie to assist yci e with any
financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors maybe in civil courtit is also important for you to understand that if an unlicensed Corrcractor
or en inkiyee c` that Indi idea or firm Is injured while working an your properly, 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 Issuedi this f_rm must be soarsated and signed by the property
owner and returned to the City of Newport Beach, Building Division; for issuing the permit.
Roil' ;t eopy of Else 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. 01
Properly Owner's Signature:
Date:
AUTHORiZAMN OF AGENT TO ACT ON PROPERTY OWNER'S BE14ALF
Excluding the Notice to Property Owner, the execution of which ( understand is my personal
respor.slbility, I hereby authorize the following person(s) to act as my agents; to apply for, sign, and file
the documents riscessary tp obtain an Owner -Builder hermit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address Of Authorzed Agent:
No
J6clare underpe airj ,e'iu.rf that a #lie uro err
3Pr5 -nail+ ilea ,,,4f ire a me �.r,-r �.. Y DWMGr r the address Hstac above and
t 1 a'ar and e ! t its Ccur r NdrE d Odp Of the C:f4r'Rrs _ „i, cv'a
!i En'E . C arZa Cr r
J?e ceYrr7t g „r E ...r:TCce r ara,efi aueB u the 3CfEeiC,✓ eS Qr_17EG .0 be ;7rESEn£EG 4Uhar
ss�e.r o ,rerfy the aropefiY owner's ;;grater
=ate: