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Home My WebLink About700 W Third St - Misc. Permit,r'o$ Planning & Building Agency Building Safety Division 20 Civic center Plaza P.O. Box 1988 (M-19) Santa Ana, C492702. . (714) 647-5800 www.santa-ana.org APP-''3 CBC 2016 An applicati specified at on for a buildin gp ermit has been sub itted in NOTICE TO PROPERTY OWNER our name listin g you elf as the builder of the property improvementsvoc-t/?- A- We are providing you with an Owner-Builder Acknowledoment and lnformation Verificatjon 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. Dear Property Owner: OWNER'S ACKNOWLEGMENT AND VERIFICATION OF INFORMATON DTRECTTONS: Read and initial each statement below to signify you underctand or verify this information. tl) h I I . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Builder" build- in"g 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 hetd 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 homeowneis 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. [-!:--, ,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. //)f I l. I understand as an "Owner-Builde/' l am the responsible party of record on the permit. I understand that I may protect hyself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. P/) tt_q. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. t') /(. U. t understand if I employ or othen r'ise engage any persons, other than California licensed Contractors, and the total ialue of my construction is at least Uve hundred dollars ($500), including labor and materials, I may be considered an "employef' under state and federal law. 2/1)t /(' V- A. I understand if I am considered an "employer" under state and Federal law, I must register with the state and federal fovernment, 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.p" / /, L I understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential Vructures 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 Conkactor. DNht/4_A. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any f inan- cial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workman- ship or materials. f ,P , ,understand I may obtain more information regarding my obligations as an "employef'from the lnternal Revenue Ser- vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- sion oflndustrial Accidents. lalso understand I may contact the California Contractors' State License Board (CSLB) at1-800- 32'l -CSLB (2752) or www.cslb.ca.qov for more information about licensed cqntraqtors. '10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party I dress: ally andoo-financiall v spo n bt pro S cons ction activ itv the fol ng ad- a)a_ [ ( ,, 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.,t P I n. 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 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 Contraclor 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. tion, or other verification acceptable to the aqencv is required to be Dresented when the permit is issued to verifv the Signature of Property Owner Date ?-t 9.osD Print name of Owner Zz-/-r^o-ye9.-6^ bo1o- 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 for my project. Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent: Address 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 fllled out the above information and certify its accuracy. Property Ownels Signature Date Note: A copy of the owner's driver's license, form notarization, or other veification acceptable to the agency is re- quired to be presented when the permit is issued to ve fy the property owner's signature. 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, Alote.' A copv of the propertv owner's driver's license. form notariza- DroDertv ow ner's siqnatu re. Print Name of Owner: