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CITY OF NEWPORT BEACH 70 1,1 nj� e
COMMUNITY DEVELOPMENT DEPARTMENT 9C
100ON
Civic Center Drive I P.O. Box �1768 G DIN wpoort Beach, CA 92658-8915
www newportbe_ ac_ h_ c_ .gov i (949) 644-3200
Dear Property Owner: NOTICE TO PROPERTY OWNER
An application for a building permit has been submitt d in your na a listing //
the property improvements specified at i /� / 9 Yoytr elf�s't a builder of
We are providing you with an Owne 6wieer Acknowledgment and Information Verification Form to
make you aware of your responsibilities and possible risk you may incur by having this
Your name as the Owner -Builder. permit issued in
We will not issue a building permit until you have read, initialed your understanding of each
Provision, signed, and returned this form
owner cannot execute this to us at our official address indicated. An agent of the
permitting authority. notice unless you, the property owner, obtain the prior approval of the
OWNER'SACKNOWtFnr_eeo.•r....
'.EI?T/ONS: Read and initial each statement below to si nif
9 y you understand or verify this information.
° <i understand a frequent practice of unlicensed persons is to have the property owner obtain an
®Owifar-Builder" building permit that erroneously implies that the property owner is providing his or her
oWh°tabor and material personally. I, as an Owner -Builder, may held liable and subject to serious
fOdncijAl 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
lre
V`01operty.
I°understand buildinohlble for the construction a dtare not hiring a licensed Contractor tos are riot required to be signed by rresponsibility.
are
assume hs b I t
is respony..
. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I
nderstand that I may protect myself from potential financial risk by hiring a licensed Contractor and
a 'ng the permit filed in his or her name instead of my own.
I understand Contractors are required by law to be licensed and bonded in California and to list
he' icense numbers on permits and contracts.
I understand if I employ or otherwise engage any persons, other than California licensed
on actors, and the total value of my construction is at least five hundred dollars ($50o), including labor
/an materials, I maybe considered an "employer' understate and federal law.
6.,_I understand if I am considered an "employer" under state and federal law, I must register with the
s e 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
by th se laws may subject me to serious financial risk.
erstand under
rnia Contractors' State
gle-falmtydresidential structures locann t legally build them Lwith the icense in intent to offer them aw, an lforrwho builds
sale, unless
11 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
Co ractor.
riderstand 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.
Form8\0e er_builder_verl£doc 08/12/16
1 of 2
v
k9.
I understand I may obtain more information regarding my obligations as an "employer" from the
s Small Business Admini
Benefit Payments, and thetCal forhe a a Divis on of Industrial Acc dents tl also undersration, the tand I miforni ay con act the
California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for
iemo information about licensed contractors.
10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and
Iega11 and financially resp nsible fr prgposed construction activity at the
rstand that I am the party wing address:
11. 1 agree that, as the party legally and financially responsible for this proposed construction
((Cctivdy, I will abide by all applicable laws and requirements that govern Owner -Builders as well as
7ny
yers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes o
f theinformation I have provided on this form.
ie rotect it
wa with someone
lho dos not have ra licenses are the Contractors' State Liced by laws designed to nse Board maybelu able to f you assist you w h 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 g understand that if an you may be held liable for
or employee of that individual or firm is injurecensed Contractor
d while working on your property, Y. Y
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 pronfigy•
permit. *
owner and returned to the City of Newport Bver's IBicendseuilingorl form otarization Dvision, for issuingt is required 2A As
Note: A copy of the property � ouster's signature.
presented when the permit i s d verify the ro erty � �� � �� ��•
Print name of property owner:
Date: 6
Property Owner's
The following tnonzauon
iesionating arlagent of th
Project Location or Address:
Name of Authorized Agent:
e
Excluding the Notice vrop
responsibility, I hereby auth ' a
the documents necessary to ob
Scope of Construction Project (or
Form is required to be completed by the property oAer only
property owner to apply for a construction permit W the
Owner, the execution of which
the following person(s) to act as my a
an Owner -Builder Permit for my proil
nrintion of Work):
is my personal
apply for, sign, and file
el No
Address of Authorized Agent:
that I am the property own or the address listed above and I
I declare under penalty of pe of the owner's driver's
uired to be presented when
personally filled out the ab information and certify its accuracy. copy
license, form the permit is issued t tloerify thther verification e property owner's acceptable
lureo the agency l 4
Date:
Property Own Signature:
Note: py of the owner's driver's license or form notarization is required to be presented when the
np is issued to verify the property owner's signature.
Forms\oumer_builder_verif.doc O8I12/16
2 0£ 2