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Home My WebLink About20166078 - PermitCity of Santa Ana Permit Counter: (714) 647-5800 20 Civic Center Plaza (M-19), Santa Ana, CA 92702 lnspection Requests: (714) 667-2738 lnspector Section: (714) 647-5853 Electrical Permit #: 2O166078 Pin #: 338OO Project Address: 501W Nineteenth St Assessor'sParcel: 002-103-19 Lot: 6 Unit: Block: A Bldg: Tract:255 Address Range: Historic: Yes Suite Range: Zoning: Rl q Ownerl Address Phone: Tenant Name Contraclor Address: Laurie & Steve Horton 501 W Nineteenth St Santa Ana, CA 927062519 (858) 922-9987 Owner-Builder 01116002 51603 01 116002 51603 0'1 116002 51600 01 116002 51603 Amount 35.35 21 .25 52.98 Qty 1.00 1.00 1.00 1.00 Fee $15.53 $35.35 $21.2s $52.98 Phone State Lic #: Lic Type: Bus. Lic #: Workers' Compensation lnsurance Carrier: Policy #: Expires: Aulh*:! Planning Conditions Plan Checked By Permit lssued By: Subject to Field: Building Permit #: Single Family Dwelling Alteration Low Voltage efl R.3, U VB cEc 2016 Notes: For burglar alarm. Misc. Receipt: Misc. Receipt: i,risc. Receipt: Total 06/06/2018 Account# Every perfiit issued shall become invalid unless the work on the site authoized by such pemit is comnenced within 180 days aftar its issuance, or if tho wotk authoized on the site by such permit is suspended or abandoned fot a peiod of 180 days aftet the tirne the wod< is commenced. lnspector MID#: 2018-143810 01 1 16002 51600 01 1 16002 51603 $21.2s $103.86 $125.11 $0.00 $125.11 Fe6 Typ6 Control Panel Low Voltage/Res General Plan Update lssuance B(tch+:44164 - 6/6/2f.tt8 iD: JG0llic€; CTYH Tr(lnsi: .45 iAccb+: Ref+ I 2u166 Fi.pt+: I,U2891:,2 - 6/6/zLtlg 12tl,y. Tr'<tnEo.:t ion fotol S l:iB . ::, I nurie & Sleve Hor.ton 6enerol PlRn Updote Fee !1 I 1 6tfl:r2- _.,1 60tt0(10" Eleclr icol r-U116tr0?- :i16(r3Cr00- ? iso i:t:+: r* r x****x***6l Zg Building Use: Job Type: Nalure of Work: Occupancy: Constr Type: Code: Planning Approval By:Date: Date: Date; Fee Total: Paid to Date: Balance Due: ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG. Site-Work Underground Pole Bases Light Standards Spas, Pool, Founlains Siqns (monument) Lile Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bonding / Grounding / UFER Transformers Torqueino Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouoh Ceilings (T-Bar Rough) Rough Service lvleter FINAL Afl5t#iT/q//bt I ) Notes, Remarks, Etc OWNER BUILDOT DELCAR-ATION I hcrcby trrrm undcr rnulry oa pcrjury lh0t I m cxcnpl lronr 'hc Cbntmcbn Liccns L!* for thc folhwinE rcasn (SL!70:11.5 Busincss md ftolcssioD Codc) Any City or Counly wni.h rcqurcs r pcnnil lo ('nslrucl- lltcr, improlc. &n,li\t or Ep,n 3iy (tucrurc. pritrto ils is\u0nc. lho requncsrte apllicanl lb, \uchpc.o,il ki filc r signc sarcmnr rhurh.rsh. il li.cnscd ttrsuanl ro lhc provnions.flh. Contrlcrors Licctrscd tiw (Chr,)lcr 9. Comnrcncin8 silh Seclion 7000 of Divnio,I of lh. Blsinc$ rnd Pofcsions Codc) or rhar he or \hc h crcmpr thcrcfrom Md rhc hash f.r rhc alk8.n dcmpri,r. Any viohrio. or sdhn 70.r 1 .5 by nny +pliclm forap@n rubjccrsrhc ipplica.t ro r.ivilpculryofno! nnc rhan 6vc hundrL{dolltr.(3500). -1, $ o*ncr ol lhc pmFny. or ny cn{loyes silh waScs rs thcn $lc mmpcnstn,n. sill do lhc wffk ud rhc {mrE h n i' utu[d or oaiercd lbr slc (56 ?O1.,1, Blsitus\ dd Prolcsbis Codc: l hc G,nrn.l( * t-iccne tf,w docs nor apply lo !n own.r oi rhc ampcny who hnlds or impmss th.mn. lrxl wl[ docs such slt himscll o. hcMll or lhmust hn or hcr o*. crphy..s. proridcd rhr ruch i.rImrtnk d mr i.rcndcd Dr oflcftd for eL ,l h.wcwi dr huildinA or iriptuvcm k $ld Bilhin onc rs ol con{,,crin tlE ONrcr BuiUs wil h!!e ltr bold.n of pFviry thlt lE or shc dil m! tirild or idrmt 0t poFny ror ttr puq-$ or -l-$owncrolth.F)pcny,onrcxclusivclr.onrrrcrinsRithliccnrdcontrlcrrsroq,nrrrucrilEpruJLrrlS..7044,Bu\iftrxd ft.tas\i.. Codc, 'f h. Coitr.ror'q l-i..nrc Law d.d\ nor rftly ro ,n own$ oftnrpcrry who builds or iDlrovcs thcrcon. and qho conlfrckforsucht,oicdswnh0A nn lkcnkd purunnr rorhcConrroctois Licensc lj*) -l amcrcmpr undcr Serion I hcrchy dl1nm utrrlcr r.nrltyol ')cr]ury DIOAAAIION I hnvc anl w,ll nrNain , Ccd ilrcorc of CoflEnr r. sclf-lnsu( fn sor*6{ .onDcn\al ion. &! lrovidcd ior b, SNrio. l7u} oa rhc Utx* C{ic. for rhc pdfonMrc. ol rh. w.rk for which rhc ,)cmn is Nucd. -l hrrc ond sillmrintrir {orkcr' conrr.nsllion insurancc- 0r rcquircd by Sccrion 17fi}.r rh. bhot codc. ror rhc pdir'tumc ol lhe work rbr which rhis Fnnil is issc{ Mywor[cF compcnsotion i,NuruEccrri( r*lj-licynx'nhcr *c] I ccni,i thil nr lhc pcrtunnamc olrhc wo.k ior whl.h rhh Nrnrir is is$cd. I \h{ll nol cmploy any pcrson in rn} mnnn.r $ n\ ro h(<,m $$jccr torhcwork.rr onpcn\dion laws ol Colifonia. rnd emrhrr irI \buld hecon'c subj..r ro rh- wortcF' conpcn\ar ion pmvi\ions of Sc.rio! 17(x) of rhc l.!hrr C{nlc. I !tull h]nh*irh .onPl! wirh rho* ttuvhions IVARNIN(;] Fa,lurc ro {.trrc so*cis coNp.n$r rM shnll uhlcrr !n cn]nl.ycr ro sininrl Fnrhic\ Md rivil lircs up r) oic huidr.d rhon$ dolhn (..{ ol conDcnsrri.n- dJDEcs rs rrrovid.d nn rh. s..rnr l{)76 .fih. l rtrr ('dl. inr.r.d r I hcrcnyarfi irnundcr rniltyolFrjury I atn lienst undlr novision otChaprcr 9 (onftncins wnh s(rion 7000) ofDivistu.l or rltr Busnrss aftl P$lcsriorN Codc, ffrl my liccne i\ in full for$ and cflsl LicenscClass:-Li.c.r Nlnb.rl coNslltisuoll.ENrllclcrNiJ I hcrby 0firn und.r Fn,lry or p.rjury rhar lhcrc h a consdcrioh Icndi.g agcncy for thc I'c fomoncc oi rhc *ork fd shict rhh p.mi is hsucd lSc.. 3097.Cir. C.). d.PPIIIANI-DECIJAAI!]N I h.Eby dtim undc, r,coally oI pcrjury onc ot rh. fdlo*iis dc.lrrxr k,ns: Dcnx'lirion PcrmiG-Ashcnos NorificiIion Fcdcrll Resukrions lTirlc.l0- Id6) -Rcquncd kxcrof Nolificllion rnd Cohryro rnrcr rF,n rb. \Lm y,Id r'F rcdqrl,ocularrm rlr'lm8 st{{n< mmNLlJc n.r.rnLEtrhlc '. rhh nmFcr r \irygfir I r',," *.0 rr'n npllMriq'/ud {.rc rhirrhc atn( rnlomurion A concc! loaN rormnly d.MN\ll1d \Dh rr"\ Fh,,,c.fr,r't "l9f9,lqt",9,urhona mnlNtrhurcsar,hhc y Appllconl or Ase4nilsMltrF-L: D01. **n*.r1r,,, Looqt ;\6'\6-r-r btEtE COMMENTS Meter Release L€nd6'i Nrm:- I = = T,lAYOR N4iguel A. Pulido MAYOR PRO TEM l,.4ichele Martinez COUNCILMEMBERS P. David Benavides Vicente Sarmiento Jose Solorio SalTinajero Juan Vlllegas Dear Property Owner An ap ACTING CITY I'ANAGER Gerardo Mouet CITY ATTORNEY Sonia R. Carvalho cLERK oF THE corJNcrL Maria D. Huizar CITY OF SANTA ANA PLANNINC & BUILDINC ACENCY 20 Civic Center Plaza P.O. Box I 988 . Santa Ana, Califomia 92702 www. santa-an a.org / p ba NOTICE TO PROPERTY OWNER ild ing ith been s b isting urself as the builder of the propertynrn rm ents ed at 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 us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prjor approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATON DI ECTIONS: Read and initial each statement below to signify you understand or yerify 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. 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 m y property 2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiri ng a licensed Contractor to assume this responsibility 3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name inste of my own I understand Contractors are required by law to be licensed and bonded in California and to list their license on permits and contracts. 6. I understand if lam considered an "employer" under state and Federal law, I must register with the state and I government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to 4 U 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the tal value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "em loyer" under state and federal law era unemployment compensation of each "employee." I also understand my failure to abide by these laws may subject me to ous financial risk _7. I 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 SANTA ANA CITY COUNCIL mpulido@sanla-ana oro Mayor Pro Tem, Ward 2 ri madinez@sanla-ana.oro vsam enro@sanla-ana oro Lso ono@sanra-ana oro P. Oavd Benaudes dbenaudes@santa-ana oro lvilleoas@santa-ana.oro slinaiero@santa-ana.oro 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. -ru\. I understand 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. Yfl- g I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue ' Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or \ryww.cslb.ca.oov for more information about licensed contractors. ^tlY&_lO.l am aware of and consent to an OwnerBuilder building permit applied for in my name, and understand that I am ' the party legally and frnancially responsible for proposed construction activity at the following ad rESS '11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers 4l-- e.l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the' t - informationi 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. 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. /Vote;f ow ner's driver's license form notarization, or other verification acceptable to the agencv is reouired to be Dresented when the Dermit is ,ss Date: t, - tr'r?Signature of Property Owner Print name of Owner Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent Phone Number of Authorized Agent 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. Property Owner's Signature Date Print Name of Owner Note:AcopyoftheW,orotherverificationacceptabtetotheagencyisrequiredlo be presented when the permit is issued to verify the property owner's signature. SANTA ANA CITY COUNCIL moulido@santa-ana.oro Mayor Pro Tem. Ward 2 mrman nezrAsanla ana.oro V'.cnre S.m enro wam'enlorasa.la 6na.oro rsolono@santa-ana oro P Oav,d Benavdes dbenavdesiAsanla ana oro lvilleoas@saol. ana.oro stimiero@sanla ana.oro AUTHORIZATION OF AGENT TO ACT ON PROPERW 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 project. Address of Authorized Agent:_ City of Santa Ana Permit Counter: (714) 647-5800 20 Civic Center Plaza (M-19), Santa Ana, CA 92702 lnspection Requests: (714) 667-2738 lnspector Section: (714) 647-5853 Electrical Permit #: 2O166078 Pin #: 338OO Project Address: 501W Nineteenth St Assessor'sParcel: 002-103-19 Lot: 6 Unit: Block: A Bldg: Tract:255 Address Range: Historic: Yes Suite Range: Zoning: Rl q Ownerl Address Phone: Tenant Name Contraclor Address: Laurie & Steve Horton 501 W Nineteenth St Santa Ana, CA 927062519 (858) 922-9987 Owner-Builder 01116002 51603 01 116002 51603 0'1 116002 51600 01 116002 51603 Amount 35.35 21 .25 52.98 Qty 1.00 1.00 1.00 1.00 Fee $15.53 $35.35 $21.2s $52.98 Phone State Lic #: Lic Type: Bus. Lic #: Workers' Compensation lnsurance Carrier: Policy #: Expires: Aulh*:! Planning Conditions Plan Checked By Permit lssued By: Subject to Field: Building Permit #: Single Family Dwelling Alteration Low Voltage efl R.3, U VB cEc 2016 Notes: For burglar alarm. Misc. Receipt: Misc. Receipt: i,risc. Receipt: Total 06/06/2018 Account# Every perfiit issued shall become invalid unless the work on the site authoized by such pemit is comnenced within 180 days aftar its issuance, or if tho wotk authoized on the site by such permit is suspended or abandoned fot a peiod of 180 days aftet the tirne the wod< is commenced. lnspector MID#: 2018-143810 01 1 16002 51600 01 1 16002 51603 $21.2s $103.86 $125.11 $0.00 $125.11 Fe6 Typ6 Control Panel Low Voltage/Res General Plan Update lssuance B(tch+:44164 - 6/6/2f.tt8 iD: JG0llicâ‚¬; CTYH Tr(lnsi: .45 iAccb+: Ref+ I 2u166 Fi.pt+: I,U2891:,2 - 6/6/zLtlg 12tl,y. Tr'<tnEo.:t ion fotol S l:iB . ::, I nurie & Sleve Hor.ton 6enerol PlRn Updote Fee !1 I 1 6tfl:r2- _.,1 60tt0(10" Eleclr icol r-U116tr0?- :i16(r3Cr00- ? iso i:t:+: r* r x****x***6l Zg Building Use: Job Type: Nalure of Work: Occupancy: Constr Type: Code: Planning Approval By:Date: Date: Date; Fee Total: Paid to Date: Balance Due: ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG. Site-Work Underground Pole Bases Light Standards Spas, Pool, Founlains Siqns (monument) Lile Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bonding / Grounding / UFER Transformers Torqueino Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouoh Ceilings (T-Bar Rough) Rough Service lvleter FINAL Afl5t#iT/q//bt I ) Notes, Remarks, Etc OWNER BUILDOT DELCAR-ATION I hcrcby trrrm undcr rnulry oa pcrjury lh0t I m cxcnpl lronr 'hc Cbntmcbn Liccns L!* for thc folhwinE rcasn (SL!70:11.5 Busincss md ftolcssioD Codc) Any City or Counly wni.h rcqurcs r pcnnil lo ('nslrucl- lltcr, improlc. &n,li\t or Ep,n 3iy (tucrurc. pritrto ils is\u0nc. lho requncsrte apllicanl lb, \uchpc.o,il ki filc r signc sarcmnr rhurh.rsh. il li.cnscd ttrsuanl ro lhc provnions.flh. Contrlcrors Licctrscd tiw (Chr,)lcr 9. Comnrcncin8 silh Seclion 7000 of Divnio,I of lh. Blsinc$ rnd Pofcsions Codc) or rhar he or \hc h crcmpr thcrcfrom Md rhc hash f.r rhc alk8.n dcmpri,r. Any viohrio. or sdhn 70.r 1 .5 by nny +pliclm forap@n rubjccrsrhc ipplica.t ro r.ivilpculryofno! nnc rhan 6vc hundrL{dolltr.(3500). -1, $ o*ncr ol lhc pmFny. or ny cn{loyes silh waScs rs thcn $lc mmpcnstn,n. sill do lhc wffk ud rhc {mrE h n i' utu[d or oaiercd lbr slc (56 ?O1.,1, Blsitus\ dd Prolcsbis Codc: l hc G,nrn.l( * t-iccne tf,w docs nor apply lo !n own.r oi rhc ampcny who hnlds or impmss th.mn. lrxl wl[ docs such slt himscll o. hcMll or lhmust hn or hcr o*. crphy..s. proridcd rhr ruch i.rImrtnk d mr i.rcndcd Dr oflcftd for eL ,l h.wcwi dr huildinA or iriptuvcm k $ld Bilhin onc rs ol con{,,crin tlE ONrcr BuiUs wil h!!e ltr bold.n of pFviry thlt lE or shc dil m! tirild or idrmt 0t poFny ror ttr puq-$ or -l-$owncrolth.F)pcny,onrcxclusivclr.onrrrcrinsRithliccnrdcontrlcrrsroq,nrrrucrilEpruJLrrlS..7044,Bu\iftrxd ft.tas\i.. Codc, 'f h. Coitr.ror'q l-i..nrc Law d.d\ nor rftly ro ,n own$ oftnrpcrry who builds or iDlrovcs thcrcon. and qho conlfrckforsucht,oicdswnh0A nn lkcnkd purunnr rorhcConrroctois Licensc lj*) -l amcrcmpr undcr Serion I hcrchy dl1nm utrrlcr r.nrltyol ')cr]ury DIOAAAIION I hnvc anl w,ll nrNain , Ccd ilrcorc of CoflEnr r. sclf-lnsu( fn sor*6{ .onDcn\al ion. &! lrovidcd ior b, SNrio. l7u} oa rhc Utx* C{ic. for rhc pdfonMrc. ol rh. w.rk for which rhc ,)cmn is Nucd. -l hrrc ond sillmrintrir {orkcr' conrr.nsllion insurancc- 0r rcquircd by Sccrion 17fi}.r rh. bhot codc. ror rhc pdir'tumc ol lhe work rbr which rhis Fnnil is issc{ Mywor[cF compcnsotion i,NuruEccrri( r*lj-licynx'nhcr *c] I ccni,i thil nr lhc pcrtunnamc olrhc wo.k ior whl.h rhh Nrnrir is is$cd. I \h{ll nol cmploy any pcrson in rn} mnnn.r $ n\ ro h(<,m $$jccr torhcwork.rr onpcn\dion laws ol Colifonia. rnd emrhrr irI \buld hecon'c subj..r ro rh- wortcF' conpcn\ar ion pmvi\ions of Sc.rio! 17(x) of rhc l.!hrr C{nlc. I !tull h]nh*irh .onPl! wirh rho* ttuvhions IVARNIN(;] Fa,lurc ro {.trrc so*cis coNp.n$r rM shnll uhlcrr !n cn]nl.ycr ro sininrl Fnrhic\ Md rivil lircs up r) oic huidr.d rhon$ dolhn (..{ ol conDcnsrri.n- dJDEcs rs rrrovid.d nn rh. s..rnr l{)76 .fih. l rtrr ('dl. inr.r.d r I hcrcnyarfi irnundcr rniltyolFrjury I atn lienst undlr novision otChaprcr 9 (onftncins wnh s(rion 7000) ofDivistu.l or rltr Busnrss aftl P$lcsriorN Codc, ffrl my liccne i\ in full for$ and cflsl LicenscClass:-Li.c.r Nlnb.rl coNslltisuoll.ENrllclcrNiJ I hcrby 0firn und.r Fn,lry or p.rjury rhar lhcrc h a consdcrioh Icndi.g agcncy for thc I'c fomoncc oi rhc *ork fd shict rhh p.mi is hsucd lSc.. 3097.Cir. C.). d.PPIIIANI-DECIJAAI!]N I h.Eby dtim undc, r,coally oI pcrjury onc ot rh. fdlo*iis dc.lrrxr k,ns: Dcnx'lirion PcrmiG-Ashcnos NorificiIion Fcdcrll Resukrions lTirlc.l0- Id6) -Rcquncd kxcrof Nolificllion rnd Cohryro rnrcr rF,n rb. \Lm y,Id r'F rcdqrl,ocularrm rlr'lm8 st{{n< mmNLlJc n.r.rnLEtrhlc '. rhh nmFcr r \irygfir I r',," *.0 rr'n npllMriq'/ud {.rc rhirrhc atn( rnlomurion A concc! loaN rormnly d.MN\ll1d \Dh rr"\ Fh,,,c.fr,r't "l9f9,lqt",9,urhona mnlNtrhurcsar,hhc y Appllconl or Ase4nilsMltrF-L: D01. **n*.r1r,,, Looqt ;\6'\6-r-r btEtE COMMENTS Meter Release Lâ‚¬nd6'i Nrm:- I = = T,lAYOR N4iguel A. Pulido MAYOR PRO TEM l,.4ichele Martinez COUNCILMEMBERS P. David Benavides Vicente Sarmiento Jose Solorio SalTinajero Juan Vlllegas Dear Property Owner An ap ACTING CITY I'ANAGER Gerardo Mouet CITY ATTORNEY Sonia R. Carvalho cLERK oF THE corJNcrL Maria D. Huizar CITY OF SANTA ANA PLANNINC & BUILDINC ACENCY 20 Civic Center Plaza P.O. Box I 988 . Santa Ana, Califomia 92702 www. santa-an a.org / p ba NOTICE TO PROPERTY OWNER ild ing ith been s b isting urself as the builder of the propertynrn rm ents ed at 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 us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prjor approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATON DI ECTIONS: Read and initial each statement below to signify you understand or yerify 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. 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 m y property 2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiri ng a licensed Contractor to assume this responsibility 3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name inste of my own I understand Contractors are required by law to be licensed and bonded in California and to list their license on permits and contracts. 6. I understand if lam considered an "employer" under state and Federal law, I must register with the state and I government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to 4 U 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the tal value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "em loyer" under state and federal law era unemployment compensation of each "employee." I also understand my failure to abide by these laws may subject me to ous financial risk _7. I 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 SANTA ANA CITY COUNCIL mpulido@sanla-ana oro Mayor Pro Tem, Ward 2 ri madinez@sanla-ana.oro vsam enro@sanla-ana oro Lso ono@sanra-ana oro P. Oavd Benaudes dbenaudes@santa-ana oro lvilleoas@santa-ana.oro slinaiero@santa-ana.oro 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. -ru\. I understand 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. Yfl- g I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue ' Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or \ryww.cslb.ca.oov for more information about licensed contractors. ^tlY&_lO.l am aware of and consent to an OwnerBuilder building permit applied for in my name, and understand that I am ' the party legally and frnancially responsible for proposed construction activity at the following ad rESS '11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers 4l-- e.l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the' t - informationi 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. 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. /Vote;f ow ner's driver's license form notarization, or other verification acceptable to the agencv is reouired to be Dresented when the Dermit is ,ss Date: t, - tr'r?Signature of Property Owner Print name of Owner Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent Phone Number of Authorized Agent 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. Property Owner's Signature Date Print Name of Owner Note:AcopyoftheW,orotherverificationacceptabtetotheagencyisrequiredlo be presented when the permit is issued to verify the property owner's signature. SANTA ANA CITY COUNCIL moulido@santa-ana.oro Mayor Pro Tem. Ward 2 mrman nezrAsanla ana.oro V'.cnre S.m enro wam'enlorasa.la 6na.oro rsolono@santa-ana oro P Oav,d Benavdes dbenavdesiAsanla ana oro lvilleoas@saol. ana.oro stimiero@sanla ana.oro AUTHORIZATION OF AGENT TO ACT ON PROPERW 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 project. Address of Authorized Agent:_