1547 W PALAIS RD (2)CITY OF ANAHEIM
BUILDING DIVISION
Permit Number: SW124ul3-00011 200 S. ANAHEIM BLVD.
Issued: 02/10/2023 17141765 -5153
www.anaheim.net/building
(714)765-0626
Quarter Section: 56
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 1547 W PALAIS RD, 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 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.
3.1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
A myself from potential risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own.
DP4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
p 5. I 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" understate 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.
r_Qn 7.1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
T 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.
_ Qap 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
�f or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
M 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.csib.ca.gov for more information about licensed contractors.
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: 1547 W PALAIS RD.
Permit Number: SW12023-00011
Issued: 02110/2023
www.anaheim.net/building
(714)765-0626
Quarter Section: 56
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714)765-5153
Permit Number: SW12023-00011
11.1 agree that, as the party Legally and financially responsible for this proposed construction activity, I will abide by all
Jl�l 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
r 0 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
courtIt 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 owners 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 owners signature.
2 -10-23
Property Owne . ignature_ ' iDate:;
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