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Home My WebLink About3873 S Main St - Misc. Permitlr o t:. a-?:: Planning & Bullding Agoncy Bulldlng Safety Divl3'ron 20 Clvlc Center Plaza P.O. Box 1988 (M-19) Senta Ana, CA 9z,02 0r4) 647-5800 www.3anta-ana.org APP-I3 CBC 2015 NOTICE TO PROPERTY OWNER Dear Property Owner: An applica tion for a buildin g perm it has been submitted in your name listing yourse lf as the builder of the rm ents 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 pormit issued in your names as the Owner-Builder. We will not issue a buiHing permit until you have read, initialed your understanding of each provision, signed, and returned this fom to u6 at our official address indicated. An agent of the owner cannot execute hls notlce unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEGiiENT ANO VERITICATION OF INFORMATON : Re'.l eN lntdaloacr, statemorrt 6erow to sEaW you uaderctd,nd or vetw thls lntonnatlon. 1. I understand a frequent practice of unllcensed persons is to have the property owner obtain an "Ownerâ‚¬uildei build- ing pamit that enonoously imdiâ‚¬s lhat the property owller is providing his or her or n labor and material peGonally. l, as an O*ner+uilder, may be hâ‚¬ld liablc and subject b serious financiat risk for any injuries sustained by an un[c6nsed person and his or her employees whle worklng on my property. My homeowneds insuralnce may not ptovide coverage fo( tiose injuries. I am wilFJlly 4t'ng as an OwnerSuilder and am aware of the limits of my insuErnce coverage for injuries to workers on my prop eftv. /N -L2. I understand building pâ‚¬rmits are not required b be signed by propcrty owners unless they arâ‚¬ responsible for the con9rc{ion and are not hin'ng a lbensed Contracbr to assu.rE thb responsibllity_ d,l, t uno.ot"nd as an 'Orvner-Buitdsr I am the respongble party of record on th6 pemit I undeGtand that I may pmtect mytelf frcm potential fnancial risk by hiring a licensâ‚¬d Contractor and having the pem[ filed in his or her name insteadof myo*.a' 0/ a. t unaerstand Contrac{ors are rtquirâ‚¬d by law to be licansed and bonded in Califomia and to list their license numbers on permlts {,, and contracts. understand if I employ or otherwise engEle any personst other than Caliirmla [censed Contractors, and the total value of my construdion ts at lâ‚¬as( five hundrcd dolars ($500), inctud ing labor and materials. I may be considercd en'ettl.ryef OL. , under state and federal law. urdersbnd ifl am consirered an'â‚¬mployef under 6tate and Federal law, I must register with the shte and lederal govemment,wlthhold payroll taxes, provile workers' compensauon disability insurance, and contsibute to unemdoymenl com-pâ‚¬nsgtion d,,of eacfi "empbyee.' I abo understand my failure b abide by these laws may subject me to sefbus financial risk. understand under Cdifomia Confactors' Srtate Licensâ‚¬ Law , an Ownor+u der who builds single-family residentialstructjres cannot legally buiH thâ‚¬m with the intent to ofrer them ior sab, unbss a/ work is perforned by licensed subconfac- brs and number of shuctures doâ‚¬s not oxceed fout within any calendar years, or all of he *ork b perbImod under contractwithgeneral building Cont'actor. I understand 6 an Osmerâ‚¬uiHer if I sell the property for which this permit is issued, I may be held liable lor any finan-ciel or pâ‚¬rsond injuries suslahed by any su ship or rnaEriab. bsequâ‚¬nt owne(s) that result from any lateril conslruction defects in lhe workma rr I understand I may obtain more information regarding my obligations as an .employef from the Internal Revenue Ser_ United States Small Busin ess Administration, the California Department of Benefit Payments, and the Califomia Divi- sion of lndustrial Accidents. I also undersland I may con tact the Califromia Contractors' State License Board (CSLB) at 1â‚¬OO- 321-CSLB (2752) or www.cslb.ca.oov for more informa tion about licensed contractors. s{," {,, dress I am aware of and consenl to an Owner-Builder build ing permitapplied for in my name, and understand that lam theparty legally and fina ncially responsible for pro posed construction activity at the follc'lvin ad- <4.> ^J 1 1. I agree that, as the party legally and flnanciall y responsible for this proposed construction activity, I willabide by allappligDle laws V ,r.,,n.. and requkements that govern Owner-B uilders as well as employers to notify the issuer of this form immediately of an y addilions, deletions, or changes to any of the information Ihave provided on this form Before a building permit can be issued, thls form must bo com pleted and signed by the property owner and ret[medto lhe agency responsible for issui ng the permit. ,rrote..fotm rs theDrope rtv own ef s s ionatu re. Signature of Property Owner Date:AOJA Print name of Owner il Licensed. contractors are regulated by laws desig;ed to protect thB public. If you contract with someone who does not have alicense, the contractors' state License. Board m-y be unable to assist you wi[\ any financial loss you may sustain as a result ofa complaint.. Your only remedy against- unliconsed contracto,s may b" in ciril couit tt is also imfortant ior you to underslandthat F an unlicensed Contractor or employee ot that indivilual or firm is injured while working on jour froperiT, you may be heldliable for damages. lf you obtain a permii as Owner-Builder and wish to hire contactors, yo-u wirioe rispbnsioti ror veriryingwhether or not those contractors are properly licensod and the status of their wo*ers' cl'mpensation in|,run.. *r"rrg". k AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Exd-uding the Notice to Propefi Owner, the execution of whictr I understand is my personal responsibility, I hereby authorizethe following person(s) to act as my agent(s) to apply for, sign, and file the documints necessary to ootain an oMler-BuilderPermit for my project. Scope of Construction POect (or Oescription of Work) Poect Location or Address 3S\3 3. Mbu"'>tr"<* Name of Authorized eS".t, f Sg+eaiLrd Address of Authorized Age nt, \5 Phone Number of Authorized Agend lroA I declare under penalty of perju F te*tl-w ff\Rt fr6{ana-C^ q>:Sf ?D- ry that I am the properv owner for the address listed above and I personally filled out the aboveinformation and cortify its accu Property Owne/s Signature Print Name of Owner h' K'ekt^^f,. Dale: S 3 0eo h Note: A copy ol tlre a nar's driver's llcense, form notarizatlon, ot othet verirication accoptable to the agency ls re-quired to be preaented vhen the pqmft la lssuea to vitfy ii'pip"rry o*r"r,s signaturc.