City of Huntington Beach Department of Public Works OWNER

City of Huntington Beach

Department of Public Works

OWNER-BUILDER VERIFICATION

2000 Main Street, Huntington Beach, CA 92648

Office: (714) 536 - 5431

Permit No. _____________

Address: ______________

______________________

An application for a grading permit has been submitted listing yourself as the builder of the property improvements specified at address

listed above.

We will not issue a grading permit until you have read, initialed your understanding of each provision, signed, and returned

this form to us via Accela Citizen Access. An agent of the owner cannot execute this notice unless you, the property owner,

obtain the prior approval of the permitting authority.

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.

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 obtain an “Owner-Builder” grading 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 an Owner-

Builder and am aware of the limits of my insurance coverage for injuries to workers on my property.

_____2. I understand grading 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-Builder” I am the responsible party of record on the permit. I understand that I may protect myself

for 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

permits or contracts.

_____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. I 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’ 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.

_____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 a subsequent owner(s) that result from any latent construction defects in the workmanship or materials.

_____9. I 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 understand that I am the party

legally and financially responsible for proposed construction activity at the following address: _________________________________

_____11. I 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. 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 the 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 those

Contractors are properly licensed and the status of their workers’ compensation insurance coverage.

Before a grading 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. (Verified by: Please Initial) ______

___________________________________ ______________________________________________ ___________________

(Print name) (Property Owner’s Signature) (Date)

OWNER-BUILDER’S DECLARATION

I hereby affirm under penalty of perjury that I am exempt from the Contractor’s State License Law for the reason(s) indicated below by

the checkmark(s), I have placed next to the applicable item(s) [Section 7031.5, Business and Professions Code: Any city or county that

requires a permit to construct, alter, improve, demolish, or repair, any structure, prior to its issuance, also requires the applicant for the

permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor’s State License Law (Chapter 9)

Commencing with Section 7000 of division 3 of the Business and professions Code] or that he or she is exempt from licensure and the

basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of

not more than five hundred dollars ($500).

(___) I, as owner of the property, or my employees with wages as their sole compensation, will do (________) all of or (_____)

portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The

Contractors’ State License Law does not apply to an owner of property who, through employees’ or personal effort, builds or improves

the property, provided that the improvements are not intended or offered for sale. If however, the building or improvement is sold within

one year of completion, the Owner-Builder will have the burden of proving that it was not built or improved for the purpose of sale.).

(___) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044,

Business and Professions Code: The Contractors’ State License Law does not apply to an owner of property who builds or improves

thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors’ State License Law.).

(___) I am exempt from licensure under the Contractor’s State License law for the following reason: ______________________

By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to

completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not

been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business

and Professions Code is available upon request when this application is submitted or at the following Web site:

http/www.leginfor.ca.gov/calaw.html.

___________________________________ ______________________________________________ ___________________

(Print name) (Property Owner’s Signature) (Date)

__________________________________________________________________________________________

AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER’S BEHALF

Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the

following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit and

other permits or approvals related to the construction project described herein.

Scope of Construction Project (or Description of Work):

Project Location or Address: ____________________________________________________________________________________

Name of Authorized Agent: _____________________________________________________________________________________

Address of Authorized Agent: ___________________________________________________________________________________

Phone Number of Authorized Agent: ______ - ______ - ________

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 certify its accuracy.

___________________________________ ______________________________________________ ___________________

(Print name) (Property Owner’s Signature) (Date)

City of Huntington Beach

Department of Public Works

OWNER-BUILDER VERIFICATION

2000 Main Street, Huntington Beach, CA 92648

Office: (714) 536 - 5431

FOR OFFICE USE ONLY

Permit Number(s) __________________________ Address: ______________________________