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X2018-3013
7,500 l/n;ver54y Dr
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION
(HSC 19825)
NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified at 25tKi UPtyl'Q51T( 'b(2\i1C
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to
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.
o�000E
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
m
<
TIONS: Read and initial each statement below to signify you understand or verify this information.
understand a frequent practice of unlicensed persons is to have the property owner obtain an
wner-Builder' building permit that erroneously implies that the property owner is providing his or her
ov�rj, fagor and material personally. I, as an Owner -Builder, may be held liable and subject to serious
fin I risk for an injuries sustained b an unlicensed person and his or her employees while working
�pE� Y� 1 Y P9
orp Fny. property. My homeowner's insurance may not provide coverage for those injuries. I am willfully
actigg as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
C_<«<(('��'ng.ine pdoperty.
«` 2. f understand building permits are not required to be signed by property owners unless they are
re3pdrfsble 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
stand that I may protect myself from potential financial risk by hiring a licensed Contractor and
having the permit filed in his or her name instead of my own.
%r.14. I understand Contractors are required by law to be licensed and bonded in California and to list
heir license numbers on permits and contracts.
I understand if I employ or otherwise engage any persons, other than California licensed
%on—tractors, and the total value of my construction is at least five hundred dollars ($500), including labor
and 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
by theTe laws may subject me to serious financial risk.
I understand under California Contractors' State License Law, an Owner -Builder who builds
ingle-family residential structures cannot legally build them with the intent to offer them for sale, 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
Teld
racct f.
—8 IPunderstand as an Owner -Builder if I sell the property for which this permit is issued, I may be
liablefor any financial or personal injuries sustained by any subsequent owner(s) that result from any
latent construction defects in the workmanship or materials.
Forms\o=er builder veri£doc 08/12/16 1 oft
Vml
I understand I may obtain more information regarding my obligations as an "employer" from the
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
r
ore information about licensed contractors.
_10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and
understand that I am the party legally and financially re onsible for proposed construction activity at the
following address: 15W J t-` W r 1�5 k, MW 9
I agree that, as the party legally and financially responsible for this proposed construction
ctivity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as
e plo rs.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to
ny 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 requiredto be o00
presented when the permit is issued to verify the property owner's signature.
Print name of property
Property Owner's
,,6-v p C(L
Date:
The following AtIthorization Form is required to be completed by the
designating an agent of the property owner to apply for a constn
Excluding the tl6ke to Property Owner, the execution of wUK I understand is my personal
responsibility, I hereblvuthorize the following person(s) to act a y agent(s) to apply for, sign, and file
the documents necessarNobtain an Owner -Builder Permit f y project.
Scope of Construction ProJeN4or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
No
I declare under penalty of rjury that I am the propertwner for the address listed above and I
personally filled out the ove information and certify its accu . Note: A copy of the owner's driver's
license, form notariz ' n, or other verification acceptable to the ag is required to be presented when
the permit is issue0fo verify the property owner's signature.
Property Ovr's Signature:
Date:
4copy of the owner's driver's license or form notarization is required to be
is issued to verify the property owner's signature.
Forms\owner builder veriidoc 08/12/16 2 of 2
the
.o
.. o
.. a
"for the„goo
Excluding the tl6ke to Property Owner, the execution of wUK I understand is my personal
responsibility, I hereblvuthorize the following person(s) to act a y agent(s) to apply for, sign, and file
the documents necessarNobtain an Owner -Builder Permit f y project.
Scope of Construction ProJeN4or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
No
I declare under penalty of rjury that I am the propertwner for the address listed above and I
personally filled out the ove information and certify its accu . Note: A copy of the owner's driver's
license, form notariz ' n, or other verification acceptable to the ag is required to be presented when
the permit is issue0fo verify the property owner's signature.
Property Ovr's Signature:
Date:
4copy of the owner's driver's license or form notarization is required to be
is issued to verify the property owner's signature.
Forms\owner builder veriidoc 08/12/16 2 of 2
the
X2018- 3013
g5 0 0 ut); bei -514y D r
City of Newport Beach Special Inspector Manual Contractor: Bruner Lindsay
Sub -contractor: Owner/Builder
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658
www.newportbeachca.ciov 1 (949) 644-3200
SPECIAL INSPECTION REPORT
Project Address: 2500 University Dr.
Permit Number: X2018-3013
Inspection Type (s): Epoxy
Inspection Date (s): 11/5/2018 (x ) Periodic ( ) Continuous
i Describelnspection, Including-Location(s): f I
honnrn nnnvv n nnmmnnt n $d rnh�r rJn%mmle into evictinn ni in !3tinn frir
12") with
List Tests Made:
Date: 11 /5/2018
Total Inspection Time Each Day:.-
— --- - - -- -
Hours: q
List. All Items Requiring Correction (include Previously Listed Uncorrected Items):
1 Comments: I
To the best of my knowledge, the work inspected was in accordance with the Building Division approved design drawings,
snecifications and amlicable workmanshiD Drovisions of the U.B.C. extent as noted above.
ecial Inspector Signature: Date:
11/5/2018
Print: Full Name: Newport Beach Registration No.:
Charles Beardslee NB -0692
Sp ciiallnapemontteport ua/25/1UID
67