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Wntern9. 1 understand I may obtain more information regarding my obligations as an "employer' from the
al Revenue Service, the United States Small Business Administration, the California Department of
Benefit 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
more information about licensed contractors.
10. 1 am aware of and
understand that I am thepa�r
,ui1U iii,y .6, �'reJz,: '�s I2�..Z
consent to an Owner -Builder building permit applied for in my name, and
y legally and financially responsij?le for proposed construction activity at the
-01SO1. 1 agree that, as the party legally and financially responsible for this proposed construction
activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as
employers.
tOJ 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.
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:
Property Owner's Signature. Ma l A Date:
Note: The following Authorization Form is required to be completed by the property owner only
,Lvhen designating an agent of the property owner to apply for a construction permit for the
Excluding the RKce to Property Owner, the execution of which I understand is
responsibility, I hereb uthorize the following person(s) to act as my agent(s) to apply
the documents necessar7iqobtain an Owner -Builder Permit for my project.
Scope of Construction Projec r Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
No
and file
I declare under penalty of perjury 1W I am the property 6VQer for the address listed above and I
personally filled out the above in ation and certify its accurac . ote: A copy of the owner's driver's
license, form notarization, nr er verification acceptable to the agenc required to be presented when
the permit is issued to ver%fythe property owner's signature.
Property Owner igriature: Date:
Note: A y of the owner's divers license o: iorm notarization is required to be
permi is issued to verify tie property owner's signature.
when the
Forms\ov er builder verif.doc 08/12/16 2 of 2