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2076 S EILEEN DR (3)Permit Number: SW12022-00126 Issued: 10/27/2022 www.anaheim.net/building (714)765.4626 Quarter Section: 56 Dear Property Owner: CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (714) 765 - 5153 OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION FORM An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at 2076 S EILEEN DR. ANAHEIM, CA 92802. We are providing you with an Owner -Builder Acknowledgement and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name 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. Directions: Read and initial each statement below to signify you understand or verify this information. 1.1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, 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 homeowners insurance may not provide coverage for those injuries. I am willfully working as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to 2. I 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. 3.1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. ( 5.1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers's compensation disability insurance, and contribute to unemployment compensation for each "employee". I also understand my failure to abide by these laws may subject me to serious financial risk. 7.1 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 all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8.1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. AD 10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: 2076 S EILEEN DR. CITY OF ANAHEIM BUILDING DIVISION Permit Number: SW12022-00126 200 S. ANAHEIM BLVD. Issued: 10/27/2022 (7141765- 5153 www.anaheim.neUbuilding (714)7654626 Quarter Section: 58 Permit Number: SW12022-00126 JA _ 11. 1 agree that, as the party Legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govem Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 1 T �U have provided on this form. Licensed contractors are regulated by laws designed to protect the public. if you contract with ' someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financialloss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It 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. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. 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. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Si a Date: m CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION RECEIVED OCT 2 7 2021 CITY OF ANAHEIM PLANNING & BUILDING DEPARTMENT AUTHORIZATION OF AGENT TO ACT ON BEHALF OF PROPERTY OWNER FORM *Per California State Law, if you, the property owner, will be coming to our office to get.a permit, we do not require you to complete this foam, however, if you are sending someone on your behalf (your agent), please complete and sign the information below. Also make sure that you have provided your agent with a signed Owner -Builder Acknowledgment and Information Verification Form. Scope Project (or Project Location or Address.. Name of Authorized Agent: i» Address of Authorized Agent: Phone Number of Authorized i of Work): -- . -_,. - IIv?.- Required Forms of Identification Attached: (Please check one of the forms of identification below in addition to the required California State Issued ID) Property Owner's California State Issued ID with: Property Deed Property Tax Bill Closed escrow document. Title Search Mortgage Bill 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 certif i i accuracy. Property Owner's Signature: �---' �-^� Date: Office Use Only: ID Verified Ownership Verifie� Documents Planning Info Permit #,► �.n2L-ovtLlP 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax OCT 2013 www.anahelm.net/building B720 CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION OWNER -BUILDER ACKNOWLEDGMENT AND INFORMATION VERIFICATION FORM *Per California State1aw, if you, the property owner, will be coming to our office to get a permit, we will provide You with this form when, you arrive. If you are sending your agent, please complete, initial; and sign the information below. Also make "sure that you have provided your agent with a signed Authorization to Act on Behalf of the Property Owner Form with'the required forms of identification. Dear Property Owner: f� ! "i Ana application for a building 7-ry ri "' ' • �`� Pp g permit has :been submitted In your.name listing yourself as the builder of the property improvements spe ified`011 1] 1 A H I'll Ill. If 1 , il� We are providing you with an'tOwnerBullder Acknowledgment andilnformation Verification Form t0 make you aware of your responsibilities, ties, and! possible, risk you may. incur. by. having this permit issued in your name as the Owner -Builder. We will not issue'a bull '"� rx, -ainitialed ding permit until you have red; your understanding of each provision, signed, and returned this formto us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owri`4�66tain'the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each statement below to signify you understand or verify this information: D1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an er-Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, 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 arl.Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2: I 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. O3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I nerstan"d that I may protect myself from potential financial risk by hiring a licensedContractor and having the permit filed in his or her name instead of my own. 4ir4. 1 understand Contractors are required by law to be licensed and bonded in California and to list license numbers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I 'may be considered an "employer" under state and federal law. L6. I understand if I am considered an "employer" under state and federal law, I must register with 09 200 S. Anaheim Blvd., Suite 145 Anaheim, Califomia 92805 (714)765-5153 Phone (714)765-4607 Fax B72MARCH 200 J.-- the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. 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 all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. W-8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. a9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and derstand that I am the party legally and financially responsible for proposed construction activity at the following address: zQZ S V i l on 0,70 � J11. 1 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. 12. 1 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. If 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. It 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. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. 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. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: " PAGE 2 O 2 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)7654607 Fax B721 ....... --.L- --�/L. :IJ:--