Owner Builder Declaration FormCITY OF CYPRESS
Building Division
5275 Orange Avenue, Cypress, California 90630
714-229-6730 – buildingpermits@ci.cypress.ca.us
PROPERTY OWNER’S PACKAGE
Disclosures & Form for Owner-Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
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 ____________________________________________________________.
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 permi tting authority.
OWNER’S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand this information.
____1. I understand a frequent practice of unlicensed persons is to have the property ow ner 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 O wner-
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 inj 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-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 ow n.
____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, an d 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 subje ct 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 any 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 im mediately 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 someon e 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 properly 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’s driver’s license, form notarization, or other verification acceptable to the agency is r equired
to be presented when the permit is issued to verify the property owner’s signature .
Signature of property owner ___________________________________________ Date: __________________
Note: The following Authorization 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 Description 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 filled out the above
information and certify its accuracy.
Note: A copy of the 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.
Property Owner’s Signature: _______________________________________ Date: _____________________