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Santa Ana, California 92702 www. san ta - ana. org / pba NOTICE TO PROPERTY OWNER Dear Property Owner An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified atlqt< ^l , / l,>..1-,.w>t Ja E{,r^- (* c1 2?06 We are providing you with an Owner-Builder Acknowledoment 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 slatement below to signify you understand or verify this information c4,l1 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. 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 property. ('4,^1 2. I understand building permits are not required to be signed by property owners unless theyare responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. a'tuV 4. I understand Contractors are required bylawto be licensed and bonded in California and to list their license numbers on permits and contracts. Ut/,4 5. I understand if I employ or othenvise 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. -44_6 I 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 compensation of each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. ali L t 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 subcontractors 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. 0?,t'4 3. I understand as an "Owner-Builder" Iam the responsible party of record on the permit. I understand that I may protect myself from potential financial rlsk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. rJcDM 8. I understand as an Owner-Builder if I sell the prrperty for which this peJ[nit is issued. I may be held liable for any financial or personal injuries suslained by any subsequent owne(s) that r6sdit from any latent construction defects in the workmanship or materials. \ ClJl e I understand I may obtain more informalion regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payrnents, and the California Division of lndustrial Accidents. I also understand I may contact the Callfornia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. U,lJllO.I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party leg address: ally and financially responsiq e for proposed construction activ ity at the following ..,c ,l I }L At'l'111.1 agree that, as the party legally and fi6ancially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. tt)il'tZ. t 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. lf 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. lt 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. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. form notarization. or other verification acceDtable to the aqency is required to be presented when the pemit is issued to verify the propeftv owner's siqnature Signature of Property Owner Date o-+/ zq ls' Print name of owner ( . r I a. Nu r^lus 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 flle the documents necessary to obtain an Owner-Builder Permit for my proiect. Scope of Construction Project (or Descriplion of Work) Name of Authorized Agent Phone Number of Authorized Agent: I declare under penalty of periury that I am the property owner for the address listed above and I personally tilled out the above information and certify its accuracy. Property Owneis Signature Print Name of Owner: Date Note: A copy of the owner's driver's license, lorm nolari2ation, or other ve ficalion acceptable to the agency is requied to be presented when the permit is issued to verify the propetry owner's signaaure. PLink:WPs1/Counter Activity/Assembly Bills/Notice to Property Form 03-13-2014 SANTA ANA CITY COUNClL MPvlrdoiosanla-ana orc Mayor Pro Teh Wad 6 sr,naâ‚¬.o6sanra'ana oro V$m e.loAsanla.ana oro MMirlrnez@sa.!a ana oro AAaâ‚¬zc!aOsanra.a.a oro P Oard Aenasdes OBenaMdes@sa.la ana orq RRevnaOsanra-a.a oro Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. lVote-' A coDv of the propertv owner's driver's license, Project Location or Address: Address of Authorized Agent:_