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NP�� CITY OF NEWPORT BEACH
r �
COMMUNITY DEVELOPMENT DEPARTMENT
BT�ILDINC DWISION
f� 100 Civio Center Drive Ir P.O. B6% 11681 Newport Beach, CA 92658-8915
www.newoortheachoagov 1 (949) 644-3200
NOTICE TO PROPERTY OWNER
Dear Property owner.
ion appiicatiomfora building permit has been submitted in you rname listing yours
the.property, improvements specified at Z�'eN cC' - o
?Ne are providing you with an Owner -Builder Acknowledgment and Inf metior
XgOIg-zg3g
3800 R;va Ave
the builder of
\-
make you aware of your responslbilities and, passible risk you may incur by having tnis'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-
provisiom 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:
iyl'S,.A CK1iITOWl.EOGIVI =NT /•kND VXERIEICA710N OP'iNPflRMATION
�FI(�hfi °l �utr}fitHr (' &L Ist&t#metltbelCzw to stgnlfy you Underetand'a vedfy°thisInforrnatton.
/i'ir
g t(of,urMoen9ed persons is to have the property owner obtain an
1"47"OheouslY Implies that the property owner is proviziing his or her
owat t as s t wner�8ulldeir, may be held liable and s<lttjabt to serious
finata 1, ` PI?k ah pG4005ad,persan and' his orhbr,eniptoye,� Nthile working
i1rT�tf,1. � �.. ° ' 1n�n�an(;e tataY net provide coverage for thaw irtgttYWi,.J'am willfully
a� � �e'tt�r�rp��hrryrts of my insuraliretover�ge�oir`�tY�itis�b workers
0,17
MY WOR"llp9h
91
1100
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x �iltt�
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.� ��"t b� �3.� aNYNG tib p Y� 57,4 J ..
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< h 34
oI understand I may obtain more information regarding my obligations as an "employer" from the
teemi-I 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
Cal fomia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for
0m 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 responsible for proposed construction. activity at the
gh—v5tly,
ing address:
1. I agree that, as the party legally and financially responsible for thisproposedconstruction
I will abide by all applicable laws and requirements that govem Owner -Builders as well as
loyers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to
any 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 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 required tobe
Presented when the permit is issued to verify the property owner's signature.
Print name of property owner f-4 F i /,�
//f�D1/�r
Property Owner's Signature: I/� - 411 Date: Ap
Note: The following Authorization Form is required to be completed bythe property; owner dn)y
when designating an agent of the properly owner to apply for a construction permit for, the
Owner -Builder.
AUTHORIZATION OF AGENT TO"ACT.ON PROPERIV
TY OWNEit'S �}EHA�F`
Excluding the Notice to Property Owner, the exegutlorl of which"{ ,unttertaii`df ;l Ifrty, p�Tsonal
the documents necessary to�obtain an:4wner-Buili
Scope of Construction Project {or.Description of W
Project tocahon orA`, i
Namebfl�