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MAYOR
MiguelA. Pulido
MAYOR PRO TEM
Sal Tinalero
COUNCILMEMBERS
Angelica Amezcua
P. David B€navides
Michele Marlinez
Roman Reyna
Vincent F. Sarmiento CITY OF SANTA ANA
PLANNINC & BUILDING ACENCY
20 Civic Center Plaza
P.O. 8ox 1988 . Santa Ana, California 92702
www.santa-ana.org /pba
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at 5.(-.+ k_
CITY MANAGER
Davad Cavazos
CITY ATTORNEY
Sonia R. Carvalho
CLERK OF THE COUNCIL
Maria D. Huizar
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.
OWNER'ACKNOWLEGMENT AND VERIFICATI N F INFORMATON
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
,fu I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Builder"
rbuilding 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
ers on my property
understand building permits are not required to be signed by property owners unless they are responsible for
nstruction and are not hiring a licensed Contractor to assume this responsibility
I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her namep
U
rns ad of my own
I understand Contractors are required by law to be licensed and bonded in California and to list lheir license
bers on permits and contracts
tota valu
I understand if lemploy or otherwise engage any persons, other than California licensed Contractors, and the
e of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an
"e ployea under state and federal law
I understand if I am considered an "employer" under state and Federal law, I must regaster with the state and
eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
NOTICE TO PROPERTY OWNER
Dear Property Owner:
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.
ungmployment compensation of each "employee." I also understand my failure to abide by these laws may subject me to
seious frnancial risk.t)
4 Lf 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
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.
"'l^6rrr*-*irt
I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any
or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
wo#manship or materials.ilc-tlLg-l 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 Bodrd
(CFLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors.I
k'tO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am
the oartv leoallv and financiallv resoonsible for orooosed construction acti),ritv at the followino;;i ; ;: * "'22' 5 3-''' <8 "'' - >' ;+\ Z* *;7- " * * " " YH " /?+ " "/+; n- ( 4l-
.-fu I agree that, as the party legally and financially responsible for this proposed construction activity, I will abade by
'allFpplicable laws and requirements that govern Owner-Builders as well as employers.
,M I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
r 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 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 whelher or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Bsfore 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. /Vo(e.' A copv of the propertv owner's driver's license.
form notarization or other verification table the c ,s uired to be when the
issued to the owner's
Signature of Property Date ,/'/5 -/ S
,
DPem.u s LLc
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),4^or{e
Project Location or Address
Name of Authorized Agent:
Address of Authorized Agent:0
q
I declare under penalty of perjury that I am the property owner for the address listed above and I personally tllled out the above
information and certify its accuracy
Property Owner's Signature Date
Print Name of Owner:
Note: A copy of the owner's driver's license, fom nota zation, ot other yerification acceptable to ahe egency is required to
be prcsented when the permit is issued to verify the propefty owner's signature,
PLink:WP51/Counter Activity/Assembly Bills/Notice to Property Form 03-13-20'14
SANTA ANA CITY COUNCIL
ature.
MPurdo@santa a.a oro
Mayor Pro Toh. Ward 6
SThaEro@sanla ana oro Vsa.mre.torAsanla.ana oro MManrn6r@s.nt.-.ne.oro AA4srclr@lalh:rur,s9
P Oavid 8en6sd€s
OB6oau!,6@entan.. oro RR.vnr@srnE-an..oro
Print name of Owner
Phone Number of Aulhorized Agent: