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Planning & Building Agency Building Safety Division 20 Civic Center Plaza P.O. Box 1988 (M-19) Santa Ana, CA 92702 (714) 647-s800 www.santa-ana.org APP-13 CBC 2016 NOTICE TO PROPERW OWNER Dear Property Owner: An application for a specified at buildin'3 z- g permit I name listi ng rself as the builder of the improvements C>qqlq 6 We are providing you with an Owner-BuilderAcknowledqment and lnformation Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your names 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 ACKNOWLEGMENT AND VERIFICATION OF INFORMATON DIRECTIONS; Read and initial each statement below to signify you understand or verify this information..^:l -|_|l/|L,f understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Builde/' build- ing permit that erroneously implies that the proper$ owner is providing his or her own labor and material personally. l, 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 as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my prop- erty.yL,nderstand 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 <M-understand as an "Owner-Builde/' I am the responsible party of record on the permit. I understand that I may protect myseF from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. ., ![L I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. rfrtL\ \/" [5 I 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 ($500), including labor and materials, I may be considered an 'gmploye/' under state and federal law. 14 understand if I am considered an "employer" under state and Federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment com- p;lnsatiggr of each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk.-tM) )_JYI understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless a// work is performed by licensed subcontrac- tors and the number of structures does not exceed four within any calendar years, or all of the work is performed under contract ffi ;ffi [JJ,*Lxffi 5iry.,%yi:it*,J:ilt#r,T;*i.ffi rffi ]:'$t*';:T:*Jrn ship or materials. q ,