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6745 E KENTUCKY AVECITY OF ANAHEIM BUILDING DIVISION Permit Number: SW12023-00023 200 S. ANAHEIM BLVD. Issued: 04/10/2023 (714) 765 - 5153 www.anaheim.net/building (714)765-0626 Quarter Section: 211 OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION FORM Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at 6745 E KENTUCKY AVE. ANAHEIM, CA 92807. 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. _VAo- 1.1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" building �' 1 permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, 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 working as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to 2.1 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. - W3. I 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. _ K4 .1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. K51'f. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" nder 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. W 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 nder contract with a licensed general building Contractor. _ 8. I 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. Kth. 1 understand 1 may obtain more information regarding my obligations as an "employer' from the internal Revenue Service, e 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 V1-800-321 ' /-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. V10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the . legally and financially responsible for proposed construction activity at the following address: 6745 E KENTUCKY Permit Number: SW1202340023 Issued: 04/10/2023 www.anaheim.net/building (714)765-4626 Quarter Section: 211 CITY OF ANAHEIM BUILDING DIVISION 200 S. ANAHEIM BLVD. (7141765.5153 Permit Number. SW12023-00023 _ W11;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. \/ 2- 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. 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 worke ' compensation insurance coverage. Before a building p it n be issued, this form must be completed and signed by the property owner and returned to the agency responsibl for iss Ing the permit. Note: A copy o prope owners driver's license, form notarization, or other verification acceptable to the agency is required to be pres t d an the rmit is issued to verify the property owners signature. -4-tf�•�� Property Owners Signature Date: RE RECEIVED CITY OF ANAHEIM PLANNING DEPARTMENT APR 10 2023 BUILDING DIVISION CITY OF ANAHEIM TANNING & BUILDING DEPARTMENT AUTHORIZATION OF AGENT TO ACT ON BEHALF OF. PROPERTY &NER 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 form, 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. Project Location or Address: of Authorized Agent: �-1 Address of Authorized G(c.� AV%F- FIJ4 Phone Number of Authorized Agent: 614q 1Z)t7q-1 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 Colifomia 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 inforr plyon and certify its accuracy. Property C Office Use ID Verified Ownership Verified Documents Planning Info Z� Permit # J IA) LW21'97-Q00 Z5 • •2.'S 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765.4607 Fax OCT 20'13 www.anaheim.neftuilding 872 . `'-.0 'iY OF ANAHEIM ; :�• PLANNING DEPARTMENT BUILDING DIVISION OWNER -BUILDER ACKNOWLEDGMENT AND INFORMATION VERIFICATION FORM *Per California State Law, 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 Prooertv Owner Form with the required forms of identification. Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at We are providing you with an Owner -Builder Acknowledgment 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 in rmation. 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an Ow n' 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 will Ily acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to w ers on my property. 2.1 understand building permits are not required to be signed by property owners unless they are r onsible 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 financial risk by hiring a licensed Contractor and h ing 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 e license numbers on permits and contracts. . I understand if I employ or otherwise engage any persons, other than Califomia licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including I r 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 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)785.4607 Fax 672 • MARCH 2009 -&.-I— --&n ..HAI-- pjr 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 gingg a to abide by these laws may subject me to serious financial risk. 7.1 understand under Califomia Contractors' State License Law, an Owner -Builder who builds a 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 Zb ing Contractor. 8.1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be hel liable for any financial or personal injuries sustained by any subsequent owners) that result from anv latent construction defects in the workmanship or materials. 9.1 understand I may obtain more information regarding my obligations as an "employer" from the emal Revenue Service, the United States Small Business Administration, the Califomia 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. 410.1 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: 1. I agree that, as the artYle all and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govem Owner -Builders as well as em I yers. 12. 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. 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 PAGE 2 OF'f 200 S. Anaheim Blvd., Sufte 145 Anaheim, California 92805 (714)765.5153 Phone (714)765.4807 Fax 6721