Fillable Form Ds-3042 Owner - Builder Verification printable pdf download

fORM

City of San Diego

Owner - Builder

Development Services

DS-3042

1222 First Ave., MS-301

Verification

San Diego, CA 92101

(619) 446-5000

2010

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PROJECT NO.: ____________________________

APPROVAL NO.: ____________________________

Dear Property Owner:

An application for a building permit has been submitted in your name listing yourself as the builder of the prop-

erty improvements specified at: ____________________________________________________________.

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 (per California Health and Safety Code Section 19825). We will not issue a building permit until

you have read, initialed your understanding of each provision, signed, and returned this form to us in person or

at the address listed above.

OWNER’S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION

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” 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 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 building permits are not required to be signed by property owners unless they are respon-

sible 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 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 permits and 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.

Printed on recycled paper. Visit our web site at

Upon request, this information is available in alternative formats for persons with disabilities.

DS-3042 (03-10)

Form Ds-3042 Owner - Builder Verification

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