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N y 1xI N m m ' m m O J < 3. !?, - 0O N F m N O n P a n N O N' O y N O W'v,ro.,r.-.r O' <R m g 1 c V w V n N O J d O d A w Sm O -w0 3- A rD rp y C w o0 o w m m a OWDN oO O]]T�) O y a w U D O C w J N wA j N N N nm - m x20 �2 CITY OF NEWPORT BEACH IOU0 SGIVIfi��0 ()V'' COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA 92658-8915 www.neWportbeachccl.gov 1 (949) 644-3200 OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION (HSC 19825) Dear Property Owner. An application for a building permiAa s 'b 'tted in Y na. n o elf as the builder of the property improvements specifiedWe are providing you with an Oer Ac le m t and"information Verification Form to make you aware of your responsibilities and possible risk you ay 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 TIONS: Read and initial each statement below to signify you understand or verify this information. 1. I 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 own labor 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 acting a .an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers Vroperty. 1 understand building permits are not required to be signed by property owners unless they are Is 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.d that I may protect myself from potential financial risk by hiring a licensed Contractor and A@Jing the permit filed in his or her name instead of my own. Iyynderstand Contractors are required bylaw to be licensed and bonded in California and to list Anse numbers on permits and contracts. I understand if I employ or otherwise engage any persons, other than California licensed fors, and the total value of my construction is at least five hundred dollars ($500), including labor terials, 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 ind federal government, withhold payroll taxes, provide workers' compensation disability insurance, peftibute to unemployment compensation for each "employee." t also understand my failure to abide >e laws may subject me to serious financial risk. fi P riderstand under California Contractors' State License Law, an Owner -Builder who builds ly residential structures cannot legally build them with the intent to offer them for sale, unless performed by licensed subcontractors and the number of structures does not exceed four calendar year, or all of the work is performed under contract with a licensed general building derstand as an Owner -Builder if I sell the property for which this permit is issued, I may be held 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. Fomes\owner builder verifdoe 04/23/13 1 Oft understand I may obtain more information regarding my obligations as an "employer' trom t;e t rnal 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 fornia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for re ipYormation about licensed contractors. 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and VCVimthat l am the party legally an financially resp able for proposed construction activity at the f owjpg address: 11. 1 agree that, as the party legally and financially responsible for this proposed construction ty, I will abide by all applicable laws and requirements that govern Owner -Builders as well as ffff 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to 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 required to be presented when the permit is issued to verify the property owner's signature. Print name of property owne . 4 /'/11-1 /_r 42 T27 q Property Owner's Signatur Date: 6 l �� Note: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: Note: A copy of the owner's driver's license or form notarization is required to be presented when the permit is issued to verify the property owner's signature. 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Box 1768 1 Newport Beach, CA 92658-8915 www.newportbeachca.gov 1(949)644-3200 Structural Observation Report Prpjec^�tltlress� Report Date: CNB Inspe' or Nam Permit: Building Owner Name: 1 Owner's Mailing Address if different from site); Owner's T lephone #: CNB Plan Check r (UL -- ❑ Concrete C . Z-acO 6 Full Name of Structural Observer (SO): -- SO E-mail Address: SO Telephone #: SO License I Reg, #: Nhh 12-21 A) REN. s-30- n 1 �. ❑ Caissons, Piles, Grade Beams ❑ Wood or Manuf. Shear Panels PLEASE INDICATE STRUCTURAL ELEMENTS AND CONNECTIONS OBSERVED (check applicable boxes) FOUNDATIONS SHEAR WALLS FRAMES DIAPHRAGMS (Floor/Roof) INDICATE LOCATION(S) OBSERVED DATE OBSERVED ❑ Conventional Footings & Slab ❑ Concrete ❑ Steel ❑ Concrete 1 construction stage to verify that the structure is in general conformance with the ❑ Mat Foundation, Prestressed Concrete ❑ Masonry ❑ Concrete ❑ Steel Deck REN. s-30- n 1 �. ❑ Caissons, Piles, Grade Beams ❑ Wood or Manuf. Shear Panels ❑ Masonry ❑ Wood ❑ Other: ❑ Other: ❑ Other: ❑ Other: ❑ ITEMS CHECKED ABOVE ARE APPROVED AND WITHOUT DEFICIENCIES. ❑ OBSERVED DEFICIENCIES AND COMMENTS: / ❑ REPORT CONTINUED ON ATTACHED PAGES. FINAL STRUCTURAL OBSERVATION REPORT: The tructure generally complies with the approved construction documents, and all observed deficiencies were corrected. I declare that the following statements are true to the best of my knowledge: 1. I am the licensed design professional retained by the owner to be in responsible Z.G� to charge of the structural observation; 2. I, or another licensed design professional whom I have designated above and is under A R `t \V my responsible charge, have performed the required site visits at each significant 1 construction stage to verify that the structure is in general conformance with the o. C-18 99 " approved cons Ion documents; 3. 1 understand th al eficie is hic ave documented must be corrected, prior to final acceptanc of t e at uctur I sypterts by the City of Newport Beach, Building REN. s-30- n 1 �. STAMP OF STRUCTURAL OBSERVER STRUCTURAL OBSERVATIOkOE5 NOT WAIVE AOREQUIREMENTS FOR BUILDING INSPECTION BYAUTHORIZED EMPLOYEES OF THE CITY OF NEWPORT BEACH.