HomeMy WebLinkAboutXR2024-0874 - Permit ApplicationO IEwvOgrm
Worksheet for Combo Building & Solar Permit Application
Print Form`\j o
City of Newport Beach -Building Division 5 Fp0.Y,
7r—Building
r Rcsidentlal NOTE: PLAN GHEGK FEES DUE AT TIME OF SUBMITTAL
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Description of Work
Use F__ ConstType
# Stories #Units (if Res)
Valuation $
New/Add SFF Remodel SFF—
Garage/New/Add F—
Material/Labor
OWNER'S NAME Last Fy��`.
First
Owner's Address
Owner's E-mail Address
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APPLICANT'S NAME '�r
Last �7k/n
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First ,N-rZ4z
Applicant's Address
Applicant's E-mail Ad/dress
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ARCHITECT/DESIGNER'S NAME Last , �' First R-_L2,tL Lic. No.
ArchitecUDesigner's Address
Architect/Designer's E-mail Address
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city L(,v 'c. . ,•,,.,, State f;
Zip `f 2:tt%aG Telephone
ENGINEER'S NAME Last
First I Lic. NoF
Engineer's Address
Engineer's E-mail Address
City State I
Zip F_ Telephoned
CONTRACTOR'S NAME/COMPANY
Lic. No. F Class F
Contractor's Address
Contractor's E-mail Address
City State F_
Zip F TelephoneF—
SETBACKS REAR SETBACKS FRONT
PERMIT NO.
SETBACKS LEFT SETBACKS RIGHT
PLAN CHECK NO.
USE ZONE DEVELOPMENT NO PLAN CHECK FEES $
CITY OF NEWPORT BEACH I* OA_Cfi5
COMMUNITY DEVELOPMENT DEPARTMENT dUlq I I�UII��j PUG
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
Dear Property Owner: NOTICE TO PROPERTY OWNER
An application for a building permit has been submitted in your r)ame listing ourself as the builder of
the property improvements specified at 2z,�
r
We are providing you with an Owner Bulder Acknowledgment and Info7 la on VenticationForm to�Z�6v
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 I,.. 11FORMATION
�CDIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
_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. 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
on my property.
it 2. 1 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.
%3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I
understand that I may protect myself from potential financial risk by hiring a licensed Contractor and
�aving the permit filed in his or her name instead of my own.
�' 4. I understand Contractors are required by law to be licensed and bonded in California and to list
their license numbers on permits and contracts.
5. I 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
a9d 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
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
these laws may subject me to serious financial risk.
7.
erstand under
ntractors' State
icense Law, an
lbuilds
single-family residential structuresocalnnotolegally build them Lwith the intent to offer them ilforrsale� 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
n actor.
�> 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.
Forms\ow er_buifder_verif.doe 08/12/16 1 of2