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X2om7-3a.25
W ° CITY OF NEWPORT BEACH 504 NG zed ®r
4 = COMMUNITY DEVELOPMENT DEPARTMENT
u ya, a BUILDING DIVISION
d 100 Civic Center Drive j P.O.Sox 1768 i Newport Beach, CA 92658-8915
9t o wwwmewnortbeachca.c
OWNER -BUILDER ACKNOWLEDGEMENT
(HSC 19
NOTICE TO PROPi
Dear Property Owner:
An application for a building permit has ub e
the property Improvements specified at
We are providing you with an Owner -Builder Ack r
Make you aware of your responsibilities and possible ri
your name as theOwner-Builder.
We will not Issue a building permit: until you ha
provision, signed, and returned this form to us at
owner cannot execute this notice unless you, the pi
Permitting authority.
OWNER'S ACKNOWLEOt3MENT AND 1
DIA C7TIONS: Read and /tilde/ each statement batowto
1. 1 understand a frequent practice of unlicensed I
Owner -Builder" building permit that erroneously impjiel
own labor and material personally. 1, as an Owner -Bu
financial risk for any Injuries sustained by an unliceoset
on my property. My homeowner's insurance may trot;
acting as an Owner -Builder and am aware of the limits'
o property.
.16
2, 1 understand building; permits are not requirs& 6
resp arose for me construction and are not hiring a diced
��\S -3. 1 understand as an "Owner -Builder t am the
understand that I'may protect myself from potential fir
��h�aaj,�l//ryryggthe permit filed in his or her name instead of my, c
i
I understand Contractors are required by law'to
eir I' ense numbers on permits and contracts.
I understand V I employ or otherwise engag
nntractors, and the total value of my construction is at
ean materials, I may be considered an °employer" under
6i t understand H I am considered an; "amp foyer un
state and federal government, withhold payroll taxis, pre
and contribute to unemployment compensation for each''
b these laws may subject me to serious financial risk.
7. I understand under California Contractors' Sta
ngla-family residential structures cannot legally build' th
all work is performed by licensed subcontractors and il
within any calendar year, or all of the work is performed
C clot.
n 8; I understand as an Owner-Bullder if I sell the pr
latent construction defects in the workmanship or materla
Fm il%after builder vaitdix 08117JI6 I of2
..,
it and Information Veriftcatioit Form :to
""4
Km . 1 understand 1 may obtain more Information rage ternat Revenue Service, the United States Small Busin
Benefit Payments, and the California Division of Industria
California Contractors' State License Board (CSLB) at
more Information about licensed contractors.
AAA I am aware of and consent to an Owner -Builds
understand that'I am the party legally and financially rear
f�Ilo)Wing address: rJCJH N1n 1�( i PY[yi
x[11. 1 agree that, as the party legally and financh
activity, I will abide by all applicable laws and require'
Vyars.
12. I agree: to notify the issuer of this form tmmedii
any of the Information I have provided on this form.
Licensed contractors are regulated by laws designed to K
who does not have a license, the Contractors' StateiLicor
financial loss you may sustain as a result of a"cont
Contractors may in civil court. It Is also important for yo
or employee of that individual or firm is Injured while work
damages,1f you obtain a permit as Owner -Builder and w
for verifying,whother or, riotthose.Contractors are prop
compensation Insurance coverage,
Before a building permit can be Issued, this form mu
owner and returned to the City of Newport Beach, gulf
Note:: A copy of the property owner's drhrers:lica
presented when the Permit is Issued to verify the prop
Print name of property owner:
Property Owner's Signature:
Note: 71te following Authorisation Form is required t
when designating an agent of the property owner
Owner Builder:
AUTHORIZATION OF AGENT TO ACTON'
Excluding the Notice to Property Owner, the execui
responsibility, I hereby authorize the following parsons) t4
the documents necessary to obtain an Owner -Builder Perrr
Scope of Construction Project (or Description of Work):
Project Location or Address: `,.2J " "MIA ,
Name of Aulhorized Agent:_t_j i1 �7C -t,�
AddressofAuthorizedAgent: UYRt' `i/✓7 �2Ar
I declare under penalty of perjury that l' am the proper)
personally filled out the above information and certify its s
license, form notarization, or other verification acceptable ti
the permit is issued to verify the pro art wn signatura,
Property Owner's Signature:
Note: A copy of the owners drivers license or form notarize
Permit is issued to verify the property owner's signature,
Fdrht}aweer builder-vtdf.doe 08/12/16 2 oft