402 N LEMON ST016
CITY OF ANAHEIM
PLANNING DEPARTMENT
BUILDING DIVISION
OWNER -BUILDER ACKNOWLEDGMENT AND INFORMATION VERIFICATION FORM
"'Per California State L3rv, 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:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified at 402 North Lemon Street
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
information.
Vewnl . I 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. 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 acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to
workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are
esponsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
Vnderstand
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I
that I may protect -myself from potential financial risk by hiring a licensed Contractor and
having the permit filed in his or her name instead of my own.
e 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list
lr license numbers on permits and contracts.
WT 5. I understand if I employ or otherwise engage any persons, other than California licensed
ontractors, 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.
VT6. I understand if I am considered an "employer' under state and federal law, I must register with
MARCH 2O09
200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)7654607 Fax 8721
the state and federal govemment, 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
le -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.
t t1'/ s. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be
he 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.
g. I understand I may obtain more information regarding my obligations as an "employer" from the
In emaI 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 Califomia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or
www.cslb.ca.gov for more information about licensed contractors.
0. 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
\adddrress:�� 2 t.� LEMotJ Sr. ANAKEImn GA OVV605
11. I agree that, as the party legally and financially responsible for this proposed construction
a Ivlty, I will abide by all applicable laws and requirements that govem Owner -Builders as well as
`\empployers.
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to
y 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 property 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 drivr's license, form notarization, or other verification acceptable
e
to the agency is required to be Ares nted when the permit is issued to verify the property owner's
signature.
JProperty Owner's Signature:__ W1LYl"+» TAaL DluA __Date: *1-4 Z L4
200 S. Anaheim Blvd., Suite 145 Anaheim, California 92605 (714)765-5153 Phone (714)765-4607 Fax I PAGE 2 OF 2
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