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Home My WebLink About2349 1%2 N Siemon St - Misc. PermitPlanning & Building Agency Building Safety Division 20 Civic Center Plaza P.O. Box 1988 (M-19) Santa Ana, CA 92702 (714) 647-5800 www.santa-ana.org aPP-13 CBC 2016 NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building rmit has been. submitted in your name listing yourself as the builder of the property improvements specified at 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 lo us at our offlcial 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 AN VERIFICATION OF INFORMATON DIRECTIONS: Read and initial each statement below to signify you understand or verify this information, tL l. t 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 his or her own labor and material personally. l, as an Owner-Builder, may be held liable and subject to serious flnancial 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. -&, I 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. U S. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect mysE'lf from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. Llk , understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. L*AS. t understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least flve hundred dollars ($500), including labor and materials, I may be considered an "employef' under state and federal law. l&a t 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- pensation of each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. -& 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 otfer 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 with a licensed general building Conlractor. -& t understand as an O\,yner-Builder if I sell the property for which this permit is issued, I may be held liable for any finan- cial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workman- ship or materials. l4p I understand I may obtain more information regarding my obllgations as an "employe/'from the lnternal Revenue Ser- vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. lalso understand I may contact the California Contractors' State License Board (CSLB) at 1-800- 321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. lfuO.l am aware of and consent to an Owner-Builder building permit applaed for in my name, and understand that I am the party legally and fmancially responsible for proposed construction activity at the following ad- dress: z> Q.l '/z A/ . > tl/'4o z-. ,r -Wa 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. L*13. I 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 flnancial 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 si ned the owner and returned to the agency responsible for issuing the permit. /Vofe.' tion, or other verification acceptable to the adencv is reauired to be presented when the permit is issued to verifv the proDeftv owner's sianature. Signature of Property Owner Print name of Owner Khtst)^Ja- /,q, -/ 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 responslbility, 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 pro]ect. Scope of Construction Project (or Description of Work)9-oez rE ta-tilr* /lL,Qr a-a\ To k- tvabVcawt OF 4z/vto\bL <* kirUtz*-t rn.4t s. tb2At;^/c$ . LNoANj / rzaU @7z.stq,x1tj-C4r)e_ a-z//UZ. /\rzt* .-O//rJ^)t4 S /uU") Prolect Location or Addres Name of Authorized Agent: /\./ , 9 lE r,4O.-\/ D*/\/6 Z3YLl *NDW/ Address of Authorlzed Agent:5-7./ 2- A/CZ4!J Vt91-*btL /lovvi^Zzo,v ,%t*dl U 1?b?4 Phone Number of Authorized Agent 7/q -7Lq-O2-{ 6 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. Date: 1//o r/a/4 Print Name of Owner:k0-,<r )^to L,/ Note: A copy of the ownels driver's license, form notarization, or other verification acceptable to the agency is rc- quired to be prcsented when the permit is issued to verify the propefty owner's signature. Date:// ? "q Property Owner's Signature: