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XXI oOS
a2 Faen2a
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 s the builder of
the property improvements specified at ' 'L2 Z �ra,C.x2s, s�5d'C �.� '12.6
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.
. °
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
.° .
° DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
Age.1.,5 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
° ov;a dalfor 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
Aing.as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my property.
U-1401 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.
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
having 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
t eir license numbers on permits and contracts.
_vgL5- 1 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
and materials, I may be considered an "employer" under state and federal law.
_48-1 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 these laws may subject me to serious financial risk.
�7 I understand under California Contractors' State License Law, an Owner -Builder who builds
single-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
Co/rry��_ractor.
. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be
he d 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.
Fortes\owner builder venfdoc 08/12/16 1 of2
Z-9. 1 understand I may obtain more information regarding my obligations as an "employer' from the
Internal 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.csib.ca.gov for
more information about licensed contractors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and
unde nd that I am the party legally and financially responsible for proposed construction activity at the
following address: 21-- ^; I G C.{– f 2.4—'
J--11. I agree that, as the party legally and financially responsible for this proposed construction
activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as
employers.
2. 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 pfdiidrty
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 requireit Wile
presented when the permit is issued to verify the property owner's signature.
Print name of property owner: MS�yct6 @tjl�J
Property Owner's
Date:
Note: The following Authorization Form is required to be completed by the property
ryhen designating an agent of the property owner to apply for a construction pel
Excluding the tice to Property Owner, the execution of which
responsibility, I herft.X authorize the following person(s) to act as my a!
the documents necessbKto obtain an Owner -Builder Permit for my projf
Scope of Construction Pro t (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
ikMd is my personal
apply for, sign, and file
I declare under penalty of perjur at I am the prop owner for the address listed above and I
personally filled out the above ' rmation and certify its ac acy. Note: A copy of the owner's drive✓s
license, form notarization, o her verification acceptable to the ency is required to be presented when
the permit is issued to v y the property owner's signature.
Property
Note: A cop of the owner's driver's license or form notarization is required to be
permit is esued to verify the property owner's signature.
Farms\owner builder verif doe 08/12/16 2 oft
when the
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