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Planning & Building Agency Building Safety Division 20 Civic Center Plaza P.O. Box 1988 (M-19) Santa Ana, CA 9?702 (7'14) 647-5800 www.santa-ana.org APP-13 CBC 2016 Dear Property Owner An application for a building sp ecified at --7/ 5 9, pqrmit has been _submitted in your name listing yourself as the builder of the property improvements ekt ttv 5'l S*-, t A,t ,, Oa Q2 7t/ / We are providing you with an Owner-Builder Acknowledqment 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 usatourofficial address indicated. An agentofthe owner cannot execute this notice unless you, the prope(y 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. ll-.L l. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Builder" build- 'ing permit that erroneously implies that the property owner is providing hisorherown laborand material personally. l, as an Owner-Builder, may be held liable and subject to serious financaal risk for any injuries sustained by an unlicensed person and hls or her employees whlle 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. N!-r. t 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. Ja-g. t understand as an "Owner-Builde/' I am the responsible pa(y of record on the permit. I understand that I may protect ''nryself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. lJ&-q. t understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts, ILL-S. t understand if I employ or otheMise 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. U.C 6. lunderstand if lam 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- pensation of each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. L L-1. I understand under California Contractors' State License Law, an Owner-Builder who builds singlejamily residential structures cannot legally build them with the intent to offer them for sale, unless a/l 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 with a licensed general building Contractor. .l.ltl "_8 I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any f inan- cial or personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the workman' ship or materials. NOTICE TO PROPERTY OWNER