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CITY OF NEWPORT BEACH
COMMUNITY DEVELOMWEN'I' IIEPARTAIEvr
BUILDING DIVISION
lilt} CaOc Center Drive I P.0 BOX 17681 Newt9rt Reach, CA 92656-851 IS
xww n9itii+r+rrdea:'a*_a-rev ] 9491544.32fk)
N2TICS TO PROPERTY OWNER
L1a3r Froperiy Qer
An appt,cbthxn for a uniddrtg parmrt has anon ;ubmottad ,n vo i, name oat N yourself as the a"'Ider of
IN p 9pany imtrovam9raa at .i 'I
+ .. #- (On e t,, e it
;i -
we are tvowdolg you sniff art C)wnar-Buddar Aden adamant arat InitamoW Vortiicatlon trtxm to
make vote Aware of vow rlgprrns4r41tas-and p owoole+ fork you mavicor av having thin patmo r55uuj in
your Mama as thin 0wner•Suildoo
We will not issue a building Parmit unfit you have read, inffisfsd your undaratandtng of each
Pravlstan, signed, and ratiarned this form to us at our odIcisl addross indtostad. An agent at trip
avmar cannot +axa„Dote thlu rintcu urlestt you, #tile property awoer. obtain the poor approwal pP Iha
ttw- Mitan9 RpItiinty
D18EC P tC3hJS; Read arse .nA,a.' r3ach atarom�ant Lak�w7a aagnrfy you ta. ratarttl su rmr+ly P7rtis rrrfc+rmaboo
4 I undofstdrrd a trrtteanr# WftCYi9r at unpcensgd eq ss: fn nave Inv tsr9party d9tarn pry
9wnrr-8urfder" coasting p«rrmn lha5 afro y tmtlirs, that trod prtpatty owner is t4,Msg nr5 sir her
wan flflCar grad=trateral par" Early I,. as an i7wntsr=6utldar; may fro hattt ItabBa nod s+�talaet tea. rcrw;:s
tinanrag! r.:,k to any mj.wtax sastarnata Uy nn utse9orssed ;•+arson and hoe or her am4loye9s white wtxxFnq
9n my Rtot:c+fy hfy nr,rn ec t s fn;a;rahCe may n94 ptovie wvarlge For th::tea tnlunga.. t am "Ay
arr..ring
as an L7wr�r_&odder aeon am aware. of tan iirrrlt5 of rtay.;easuran;.e _ age ibr rniunea t9 vmr+ints
Worie,
n2. 7 ancwl arnt txx4datg penises are rust M wific W tee Signed by roo0eny Owman unless thrY non
raSprUrrW.9MF for the comitructice and are Mat hiring a imensract C:antra_rtor rn agn:".cnr tins rrlsiltansibitffy
S. unaorntand a4 an ter- a hie I am ties vas t3n5 bla warty of Mord M !ha pang lt, r
ivi4 ars4ano inal I may ptutact nhysrlt {ruin po wn14 ranar :-jai .is . by hmng 0 Inensad can vactoe. and
1ea;09 b1a p-email fdad in Fish at her dam, mduad of my awn.
Itnnc5E. I undemand Canvurs asp rrafyuned by taw to be iu,erread an(! bundled its Gailrom+a ask! 0 I954
rr,.ar*e numbors oft p"milin ain and ltocL
f Understand It I employ or Otherwise onquile any era±Kars, dinar than Csiltmia P,t`areod
UaMlrlCtara, find rho fault value 9r my construCtwn to at ihaer five re frdtad dosarx (SSW), matudmll labor
aria martinatr,. !nosy ba nsede+rrrd In "ampaidynr' imder state arm federal few
4ag. I u114srxtarn,! it I am cDtsrdatad An'6otl "(, uAder start a q! federal low, l trust rCp}flldt wart trip
state and federal oavammeM, withheld payiolt lavers, txovrdn worfers ,.c rntrdn4mran dlsartifly rrtsurancaa
and camnhnta ie7 Urtnm;r?oymertf commPansapun fnulach `tnnpfyyaa." t eteu understand my failure to abldo
Vhy! age laws may auttie+ct the to se bus ti"ncial risk
T.. I undtrrstand pnd+N i;altfornfa COfifrattolm State Limnais law, an 0smat-Fivador who buiidu
sn -Rnm4y r wdenfial rtfueiums cannot tea8lly twitd main with rho #front to offer th»rn fur safe., Dotes%
ON wrtrk ix MffVmad by gcsnsad aufacesntm e4am now are nurnfsax Of ytruLw as does not eytaad tout
wham any c da edar yusr, or art of the work is pefformcd undue contract . with n lieopled I huintnq:.
i',oWntmctor
42t.. I uri4er5taM a5 an L'Fwnar-i uarfrt if i aelr the ompeny, tar Which tnkt P Mtni1 15 155ued. i MAY be
held liable Ira any finam;ad Of pen irmal inlunrs mistanad by any cut "mama owner(sl that reguit from any
latent Gonetrucfiun daiacts W: fh9 workmal"atrto or molbrath
.,.rw _ i.,. .c,.,-a .`u t, _. i nil„
c%{7! 9. I understand I may obtain Mote uttormaDon regarding my obil dawns as an "6nnpl6ye( tram Irtu
Internal Revenue Sarviva, the United States Small BiixitleAa Adminititratidn. it* Coliliottse Department 01
'BereN Payments, and the Galiforrlb DvrsKJn of Industrial Accidents I ass understand I may Contact ChB
C&iifom,a Centractnro State License Board IESLBi at 1-600-3.21-CS1.5 f2152) Ew vvww.rAib,ca pov I -
more uatormavon about licensed cmtr ciom
10 I am aware of anti consent to an Clwnet,guader building permit apptord for inMytrine, and
understand trial I ant flat party legally and tinanodtty rasp( nave frtr proposed crinstruciarin activity at ft'o
/ftliiintiing adidfass
zolv_1 t I agree tnat. as die party legally and frnancally responcibtg for this ptaposed Wrstnietiori
ireffivit i will abide by aft appllceble- laws and rst uaertisrtis that govem Owner -Su fdera As % Sx
employem
12 1 ;Nree to tuibly pie Ibauw of dto rotor immediately of any addruoris. ditletr0n5- of melanges to
:any of the tntom7ation I have provided on inis form.
'LKIensed cantrastdrs:are re*guyated by laws 4eV9n-ad TO protect tiro public It Yuu confraet with xomwcne
who dots not have a licar+se the Gdrtrnetii,i State Lrtsnast Board may be anabla to asstat yuu with any
financial loab. ywi may sustain as a result of a Wipiutni.. You, .only Fatherly against unlicensed
CeMitri 'ors may be In civil own it w also important for you to understand that if all unbcanead Contractor
or emptdyea of that individual or firm is refuted wntto wontung on your Property, You may be held liable tot
damages If you obtain apermit as Owner -Builder an4 wish to now Canvannm, you wit be reaponaltle
fw verifying wtiamar or rKn those Contrar.tors are progeny lWa:t1e<i arul the a39tua of their Wr kory
c.:umtwn7atian insurance towrafie
Before it building permit can us issued, this form must be CoMpiafed and signed by the property
owner and returned to the City of Newport Beech, Building division. for Issuing the permit.
Note: A copy of tire property owner's driver'x ticartsa or form notatisaUerl fs requited to be
presented when the permit is issued to verify the property owner's signature.
Print riarno of vropany &Wt1W � A•'�"- _
�'
oropertyOvaaeraSignelute_ rr.+.-.� ." Gale- - 4 !
More i Ile tffrayntrg AuWaartxafran Foirn is rogttirod to be computed by the property orwtlat only
wnert an agent Jul via property rdwner ro apply fora ctinsrrueftorr parmil for ino
Owner �svrld&
AUTHORtZA710N OF AGENT TO ACT ON PROPERTY OWNER'S UEMLE
`rckrdaig file Notiru to Property Owner, ins execution of whicht unoeratar4 i, my per3uribi
resporisibreiy. I hereby authotxr. it* todowi ng ;ierson(sl to act as my apant(s) to apply tor. sign. and Me
mu dGGum ants nwcrs.auty m otriaut an Owarr-Bullion Permit for my project.
Scotty of Cons nfct••on Ptojact (Or oascripurm of Wont}.
pratr cl lr -A oo 6t Adorns ' 3+.1. 6rl4 :,"f t+_v
Name ofAiilhoritellAgent 2A I .y1L:L,
Addre"OtAtif,orazed AgentL'LNY [•hoer . Lit j\j2,..�}x.h Yt'_ 6e44A., CA t0l4'6
I declare under ponafty, di -perjury feel I am #is property cwrret for the address hated above and I
Personally f ffed out the above information and certify as accuracy, More A copy rit life owr,ar'n drtvor-4
iocan:a, form ntaturmabn, or other Vertu afton accete(AiNe to Ina amity +a required 10 be presented ,avian
ftie yr.-rrnrt is Isyuud to wrmy Ina proptirtUrtnrN f'taturc
,
Property owner a Sionalure: ,Jane s �f
Nate. A t*py of the owners direr s Noon" of form notartiatirni is required to ba presented when the
permit 1p tusued id vei••ify the property owner s tlgnai,Ne
=n.• o-«i r ^w;.so-,.r.,itakt CA 1l ix. ;: of