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I understand I may obtain more inbrmation regarding my obligations as an "employef'from the lntemal Revenue Ser-
the United States Small Business Administration, the Calibmia Department of Benefit Payments, and the California Divi-
of lndustrial Accidents. I also understand I may contact the Califiornia Contractorc' State License Board (CSLB) at 1-800-
321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the
for at 1z t)l'n,l/v2 NAo
/^i
/ N )11. I agree that, as the party legally and financially responsible for this proposed construction activity, t will abide by all
hfpfrcable laws and requirements that govern Owner-Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
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 br 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 br 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 oovemge.
Before a building permit can be issued, this form must bc completed and signed by tha proporty owner and returncd
to the agency rcsponsible for issuing the permit. Note: A coov of the orooerfrr owner's driver's license, form notarlza-
proDettv owner's sionatu re.
Signature of Property Owner hvo,*
A as+o rona.
a /v I zDzoDate:
Print name of Owner a-4 L!)A
a
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 peson(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder
Permit br my p@ect.
Scope of Construction Project (or Description of Work)
Project Location or Address:
Name 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 filled out the above
information and certify its accuracy.
Property Ownef s Signature:Date:
Print Name of Owner:
Note: A copy ol the owner's driver's license, form nobrlzafron, or other verification accephble to the agency is r*
quired to be presented when the permit is issued to verily the propfi owner's slgnature.
Planning & Building Agency '
Buildlng Safety Division
20 Clvic Ccntcr Plaza
P.O. Box 1988 (ii-{g}
Santa Ana, CA 92702
(7141647{800
www,santa-ana,org
APP-I3 CBC 2016
NOTICE TO PROPERW OWNER
Dear Property Owner:
An application for a bu as the the property improvements
specified at OA,)AA
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 retumed 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.
OWNER'S ACKNOWLEGMENT AND VERIFICATION OF INFORMATON
DrRECfrOilS.' Read and initial each sbtement below to signify you understand or verify this information.
-'11
. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Builde/' build-'ffil y'ermitthat enoneously implies that the property owner is providing his or her own labor and material personally. l, as an
5/ner-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 homeowne/s insuranoe may not provide @verage 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.
nderstand building permits are not required to be signed by prope$ owners unless they are responsible f6r the
and are not hiring a licensed Contractor to assume this responsibility.
/,1 ILM. I understand as an'Owner-Builder" lam the responsible party of record on the permit. I understand that I may protect
@y#tt from potentialfinancial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
,/)
IN-A I understand Contractors are required by law to be licensed and bonded in Califomia and to list their license numbers
U6dermits and contracts.
/.)
[/LS. t understand if I employ or othenrise engage any persons, other than Califomia licensed Contractors, and the total
Ktarte of my construction is at least five hundred dollars ($5001, including labor and materials, I may be considered an
"employef under state and federal law.
@rU I understrand if I am considered an "employe/' under state and Federal law, I must register with the state and federal
(odmment, withhold payrolltaxes, 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.
OL, I understand under Calibmia Contractors' State License Law, an Owner-Builder who builds single-f;amily residential
Hr{ctures cannot legally build them with the intent to offer them for sale, unless allwork 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 generalbuilding Contractor.
..\
Ah. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any finan-
c$1y'r personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workman-
ship or materials.
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