BLD-2023-2426_Owner BuilderII
CUPERTINO
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILD ING D IVI SION
10300 TORRE AVENUE• CUPERT INO , CA 95014-3;255
(408) 777-3228 • FAX (408) 777-3333 • building@cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS l CJ?, I lo P (JI , IC-C 't-rc,l,,( fp,.,;,r j:t 2-I APN 326--?,2 ,,_ooi I BP#
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DESCRIPTION OF WORK:
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We are providing you with an Owner-Bui ld er Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this perm it issued in your name as the Owner-B uilder . 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 notic e unless
you , the property owner, obtain the prior approval of the perm itting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please 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-
Bui ld er" building permit that erroneous ly impli es that the property owner is providing hi s or her own labor and material
personally . I, as an Owner-B uilder, may be held li ab le and subject to serious financial risk for any inju ries sustained by
an unlicensed person and hi s 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
in surance coverage for injuries to workers on my prop erty .
__ 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 respons ibility.
__ · 3. I understand as an "Owner-Bu ild er" I am the responsible party of record on the permit. I understand that I may
protect myself from pote ntial financ ial risk by hiring a licensed Contractor and having the permit filed in his or her
name in stead of my own .
__ 4 . I understand Contractors are required by law to be licensed and bonded in Californ ia and to list their licens e
numbers on permits and contracts .
__ 5 . I understand if I employ or otherwise engage any persons, other than Cal ifornia 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 cons idered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability in surance, and contr ibute to
unemployment compensation for each "e mployee ." I also understand my failure to abide by these laws may subject
me to ser iou s 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 sa le, 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 a n Owner-Builder if I sell the property for which this permit is issued, I may be held li ab le for
any financial or personal injuries sustained by any subsequent owner(s) that res ult from any latent construction
defects in the workmanship or mate rials.
Owner8uilderForm_2010 .doc rev is ed 04 /14/10
DocuSign Envelope ID: 2857ABC4-A186-4990-A123-BC9485ACD336
__ 9. I understand I may obtain more information regarding my obligations as an "e mployer" 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 site address listed above.
__ 11 . I agree that , as the party legally and financially responsible for this proposed construction activity , I will abide
by all applicable law s and re quire ments that govern Owner-Builders as well as emp loy ers.
__ 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 publi c. 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 unlic ense d
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that indivigu al or firm is injured while working on your property, you may be held liable for damages . If
you obtain a perm it as Owner-Builder and wish to hire Contractors , you will be responsibl e for verifying whether or no t
those Contractors are properly licensed and the status of their workers ' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS : Please complete the following construction lending agency inform ation.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permi t is issued
(Sec 3097 Civ .)
Lender Name : ______________ Lender Address : __________________ _
Before a building permit can be issued, this form must be completed and signed by the property owne r 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 city may be required to be presented when the permit is is su ed
to verify the property owner's siqnature.
Property Owner's Signature : _______________________ Date : _____ _
-----------------------------------------. --- ---- ------- - -----------------. --}. ------------------------ ------------------- ----- - --------------
(NOTE: The following Authoriza tion Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
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 for my project.
Scope of Construction Project (or De scription of Work): ___________________ _
Project Location or Address : _____________________________ _
Name of Authorized Agent: ___________________ Tel No ________ _
Address of Authorized Agent: _____________________________ _
I declare under penalty of perjury that I am the property owner for the address listed above and I personally fill e d out the
above information and certify its accuracy. Note : A copy of the property owner's driver's licens e, form notarization , or other
verification acceptable to the city m ay be required to be presented when the p ermit is issued to verify the property owner's
signature.
Property Owner's Signature : __________________ Date : _________ _
Own er/3ui/de rFo rm_ 20 I 0.du c revised 04/14/10
DocuSign Envelope ID: 2857ABC4-A186-4990-A123-BC9485ACD336
11/2/2023