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Building&S�fety Division
21810 Coprey Drive
Diamond Baz, California 41?65
(909)834-7{l2fl Fa�t(949)$61-3117
Job Address � tS �F�(L�EN D R.._ Ol1tu1 p ti+� �3 h�
Dear Property Owner
An app6catwn for a budd�ng pertn�t has b�n submitted in your name statmg yourseff as the bu�lder af the
P�oPerty improvements spec�ed
For your pro#eation,you should be aware that es"owner-bwlder°you are the respons�ble party of record an
such a permi! Budding permits are�ot required to be sgned 6y property owners unless they are�rsonally
perCorming their awn work If your wark is be�ng performed by semeone other than yaur&elf, you may protect yourself
from poss�ble 6abddy rf khat person appl�es far the proper permd m h�s or her name
Carrtractors are reqwred by taw to be 6censed and bonded by the State of Galdorrna and to have a business
Ircense from the C�ty of County They are also requ�red by law to put the�r license number on all permds for which they
�PP�Y
If you employ ar othenvise engage any persans other than your immed�ate fam�ly, a�d the work (mclud�ng
mater�ais and other costs}is$2Q0 00 or more for the entve pr�ect, and such persona are nof licensed as contractors
or subcantractors, then you may 6e an empinyer
if you are an employer, you must register wdh the state and federal gavemment as an ampiayer and you are
sutaaect to several o6ligations�nclud�ng state and federal income tax wRhhold�ng, federal sc�cial security taxes,workers
compensation msurance,disabd�ty msurance cpsts,and unemploymerrt compensation contnbuhons
There may be financial nsks fa you rf yqu do not carry qut these obi�gattons, and these nsks are espec�aiiy
senous wdh respect to workers campensat�on insurance
For more specrfic mforrnation about yaur ob6gat�ons under the federal iaw,cantact the Internai Rev�ew Serv�ce
{and if you w�sh,tfie U S Smafl Business Admm�strabon) Far more spec�fic informat�on about yaur ab6gations under
State law, corrtact the Oepartment af Benefit-Paymetrts and the D�v�s�on of IndustrFal Accu7ents
If the structure is tntended far sale,the prope�ty owners wha are nat licensed contractors are allowed ta
perform their wo�lt personally or through their own empiayees,without a I�censed contractor ar subcontractar, aniy
under Om�ted conddions
A frequent practice of un6censed persons professmg ta 6e contractors is to secure an "awnerd�udde�'butldmg
permit,erroneously impiyrng that the property awner is providmg h�s or her own tabor and matenais personally
Budding permds are not reqwred to be signed by the property aw�rs untess they are performmg the�r own wc�rk
personally
Informatian abeut hcensed corrtractors may be obtained by ccntactmg the Contractws 3tate License Board at
9821 Business Park Onve, Sacramenta, CA 95827, www csi6 ca qqv or at{864}321-CSLB(2752)
Piease compiete and retum the enciosed"Owner-Butider"verrfication form so that we can aanfirtn that you are
aware of these matters The buddmg permit wtlI ncst he issued urrt�i the verdication is returned
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Bailding &Sa£ety I?ivieion
21$25 Capley I?rive
Diamand Baz,CaliEarn'sa 91T65
�9��ss�-�o�a Fa�{�a��sei-sii�
Attention Propetty Owner
An"Owner-Bwlde� budding petmd has been apphed for in your name and beanng yaur s�gnature
Piease complete and retum this �nformat�c�n at your earl�est apportunity to aveaid unnecessary delay m process��g and
�ssu�ng your buildrng perm�t No hu�kiing peRnit will be issued until this venficat�on �s recerved by us
1 I personally piar�to prawde the malor labor and mater�als for canstruck�an of the proposed property
improvement(yes ar no) �!ES
2 I {havefiave not) i�t Av � s�gned an applicatian for a budding pemrd for the proposed work
3 I have contracted vnth the faflow�ng person(ferm)to prov�le the proposed cansteuction
Name Address City
Pho�e Cpntractors License Na
4 I plan to provide partions af the work, but I have hired the f�lia,v�ng person to coordmate, supen+rse and
provide the maaar work
Name Address C�ty
Phone Contractars��cense No
5 I w�ll prov�de some af the work but I have contracted{hiredj the follo�tnng persons to prov�de the work
�ndicated
Name Addeess Phane Type af Work
Signed ��}� .�a;r2.t.L,��
Praperty Own
Date '7 J l � �-!1!f�
NOTICE TO PROPERTY OWNER
Dear Property Owner
An application for a bwlding permit has been submitted in your name listing yourself as the bwlder of the property
improvementsspec�edat Li5 F'P0.9fN ak � e�A�oNd 6n2
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibdities and possible risk you may incur by having this permd issued in your name as the Owner-Budder
We will not issue a bwlding permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address mdicated An agent of the owner cannot execute this notice unless you,
the property owner, obtain the prior approval of the permitting authonty
OWNER'S ACKNOWLEDGEMENT AND VERIFICATION
DIRECTIONS Read and initial each statement below to signify you understand or verify this information
�1 I understand a frequent practice of unlicensed persons is to have the property owner obtam an "Owner-
Bwlder' building permd that erroneously implies that the property owner is providing his or her own labor and material
personally I, as an Owner-Bwlder, may be held liable and sub�ect to serious financial risk for any in�unes susta�ned by
an unlicensed person and his or her employees while working on my propeRy My homeowners insurance may not
provide coverage for those in�uries I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for in�uries 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
�3 I understand as an "Owner-Budder' I am the responsible party of record on the permd I understand 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
�4 I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on pertnits and contracts
�'! 5 I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tofal value of my construction is at least five hundred dollars($500), including labor and matenals, I may be considered
an "employer' under state and federal law
�6 I understand if I am considered an "employer' under state and federal law, I must register with the state and
federal government, wRhhold payroll taxes, provide workers' compensation disabildy insurance, and contribute to
unemployment compensation for each "employee" I also understand my failure to ab�de by these laws may sub�ect
me to serious financial risk
�7 I understand under California Contractors' State License Law, an Owner-Builder who bwlds single-family
residential structures cannot legally bwld 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 w�thin any calendar year, or all of the work
is performed under contract with a licensed general building Contractor
�8 I understand as an Owner-Builder rf I sell the property for which this perm�t is issued, I may be held liable for
any financial or personal in�uries sustained by any subsequent owner(s)that result from any latent construction defects
in the workmanship or matenals
. � '�' '
�9 I understand I may obtam more informetion regarding my obhgations as an "employer" from the Intemal
Revenue Serv�ce, the Unded States Small Busmess Administration, the Cal�fom�a Department of 8enefd Peyments,
and the Cahfomia Drvis�on of Industnal Accidents I also understand 1 may contact the Cal�fom�a Contractars' State
License Board(CSLB)at 1-800-321-CSLB {2752}qr www csib ca qov for more infortnation ahaut licensed contractors
�1 t7 I am aware of and cansent to an Qwner-Budder buddmg pertmt appl�ed far m my name, and understand that i
sm the paRy Iegaily and financ�aliy responsible for proposed constructwn acttvity at the foliowing address
��11 1 agree that, as the party Iegaily and financ�aiiy responsibie for this propased canstructwn actEwty, I anii abide
by aii appiicabie iaws and requ�remerits that gavem Owner-Bu�iders as weii as empiayers
� 12 ! agree ta notity the �ssuar of thEs form �mmed��tety of any add�trons, deietions, or changes to any af the
i�fortnatwn i have prov�ded an this fortn I�rcensed cantractors are regulated by laws des�gned ta protect the public If
yau coritract with sameane who does not have a license,the Cantractors'State license Board may be unable to assist
yau wtth any fi�ancial lass you may sustain as a result of a compla�nt Your only remedy agamst unhcensed
Cpntractors may be m av�l caurt It�s also importa�t for ypu to understand that if an unhcensed Contractor or employee
af that mdmdual or firm is m�ured whtle warking an your property, you may be held hable for damages If you obtam a
permit as Owner-Builder and wish to hire Cantractors, you wiA be respons�ble for verifymg whether or not those
Contractors are properly I�censed and the status of the�r workers'compensat�on insurance coverage
Bsfoee a buddmg pertnd can he�ssued, this form must be canpfeted and signed by the property owner and returned to
the agency respons�ble for issuing the permit
Nate A copy af the property ownets dnver's la�nse,farrn notanzation,or ather venfication acceptabie to the agenay�s
raqu�res!to be presc�nted wtren the pertnd�s�ssued to veMy the praperty awrrer's s�gnature
Signature of PropeRy Owner ���YG�Z� �a?i2.t,.P�mr"�7 Date __c�L� G�I �