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Home My WebLink About512 W Seventeenth St - Misc. PermitPlanning & Building Agency Building Safoty Division 20 Civic Centor Plaza P.O. Box 1988 (M-19) Santa Ana, CA 92702 (7{4) 647-5800 rvww.santa-ana.org APP-13 CBC 2016 NOTICE TO PROPERTY OWNER An applicati specifled at on for a ildin 9pe rmit has been submitted in ur name listi ng you rself as the builder of the prope rty improvements}| 5-r.5ur bl c 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 offlcjal address indicated. An agent of the owner caniot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEGMENT AND VERIFICATION OF INFORMATON D/RECIIOIVS: Read and initial each statement below to signify you understand or verify this information. :aL1 . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Buildef' 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 sub.iect to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowneds insurance may not provide coverage for those iniuries. 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. --P),' Z)_2 I understand building permits are not required to be signed by property owners unless they are responsible for the 'construction and are not hrring a licensed Contractor to assume this responsibility. 4Z I understand as an "Owner-Builde/' I am the responsible party of record on the permit. I understand that I may protect 4yâ‚¬ell trcm potentral flnancial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers its and contracts. ue of I understand if I employ or otheMise engage any persons, other than California licensed Contractors, and the total my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employea' under state and federal law. .4.2Z6. I understand if I am considered an "employed' 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- pe nsation of each "em ployee." I also understand my failure to abide bythese laws may subject me to serious financial risk I understand under Califcrnia Contractors' State License Law, an Owner-Builder who builds single-family residential res cannot legally build them with the intent to offer 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 Contractor. understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any finan- r personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workman- Dear Property Owner; ship or materials -fu , understand I may obtain more information regarding my obligations as an "employef'from the lnternal Revenue Ser- .r/ice, tfD United States Small Business Administration, the California D?partment of Benefit Payments, and the California Divi- 'sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- 321-CSLB (2752) ot r,',r,',,r csi: :: rlf for more information abou[ licensed contractors. -4 . * lO. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the . dartv leqallv and financially responsible for proposed construction activity at the following ad- i,"i'r,-BrZ W,l{Y\{ 5f. ,S"itE \oD inxirp. es@ -,2 {a't I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all -applicable laws and requirements tnat govern Owner-Builders as well as employers. Z',, 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 havea 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 a/-$eloie a building pormit can be issuod, this form must be complotod rnd signed by tho proporty ownor and returnod . 1 \dthe agency responsiblâ‚¬ for issuing the permit. ,Vofe: A coov of the propertv owner's driver's license. form notariza- iion, or other verification acceotable to the aoencv is reouired to be prcsented when the Dermit is issued to verifu the propertv owner's s i a n atu re. Signature of Property Owner Date: G II Zo Print name of Owner EfrlE>iD q / t7l7\.) w 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 file the documents necessary to obtain an Owner-Builder Permit icr my project. Scope of Construction Project (or Description of Work)tJn rr{Ds CH I S Proje ct Location or Address: 5\2 h]' l-fHST 9v o 5 A c-A. q2 Dtr, Name of Authorized Agent:5.-,DDS. Address of Authorized Agent:t v,l. t.1Td sr.Su E\9o 5 .i cA. qz-]oB (r r'r) nBo - \6tsQ2 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 Z_O r ( tr.-, E >TD C.OL +r.r l.) Note: A copy of the owner's driver's license, form notaization, or other verification acceptable to the agency is re- quired to be presented when the permit is issued to verify the property owner's signature. Phone Number of Authorized Agent: Print Name of Owner: