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Jer9. 1 understand I may obtain more information regarding my obligations as an "employer" from the
nal 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.
ier0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and
serstand that I am the party legally and financially responsible for proposed construction activity at the
following address: _ �f 1� Qw�AOi� ) GVT�Po
11. 1 agree that, as the party legally and financially responsible for this proposed construction
a ' ity, I 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
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 tho 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: Mmmi�_\- /
Property Owners Signature: 'v Date: 3 2
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
Excluding the otice to Property Owner, the execution of which I understand is my personal
responsibility, I he authorize the following person(s) to act as my agent(s) to apply for, sign, and file
the documents necess to obtain an Owner -Builder Permit for my project.
Scope of Construction Prol (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the pebpeirty owner for the address listed above and I
personally filled out the above information and certify its uracy. Note: A copy of the owner's driver's
license, form notarization, or other verification acceptable to t gency is required to be presented when
the permit is issued to verify the property owner's signature.
Property Ownefs�Signature: Date:
Note: , copy of the owner's drivers license or form notarization is required to
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it is issued to verify the property owners signature.
Forms\owner builder verifdoc 08/12/16 2 of
presented when the