10193413 - Permit (3) - Laserfiche WebLink

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licensed subcontractors and the number of structures does not exceed four within any calendar years, or all ol the work is performed under contract with a licensed general building Contractor. i/'i a t understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any fin'arrcial or personal injuries sustained by any subsequent owner(s) that resuli from any latent construction delects in the workmanship or materials. 'D'l S. t understand I may obtain more inlormation regarding my obligations as an "employer" Irom the lnternal Flevenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the Calilornia Division of lndustrial Accidents. I also understand I may conlact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. \/l lO.l am aware ot and consent to an OwnerBuilder building permit applied for in my name, and understand that I am the party I address: ally and f ina nciall res onsible forv pro constru tlon act at theA--- llowino(4ivitylo ,2E'l'1. I agree that, as the party legally and linancially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 'l/ \ P. I agree to notily the issuer of this form immediately of any additions, deletions, or changes to any of the intormation I have provided on this form. Licensed contractors are regulated by laws designed to protecl the public. lf you contract with someone who does not have a license, the Contractors' State License Board may be unable lo 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. lt is also important lor you to understand that if an unlicensed Contractor or employee ol that individual or firm is injured while working on your property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verilying 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 musl be completed and signed by the property owner and relurned to lhe agency responsible lor issuing the permil. Note: A copv of the Dropertv owner's driver's license, form notarization or other verification ble to the /s uired lo be the it iscn Signatu re of Property Owner Date: 1 3- l7- AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, lhe execution ol which I understand is my personal responsibility. I hereby authorize the following person(s) to acl as my agent(s) to apply for, sign, and lile lhe documenls necessary to obtain an Owner-Builder Permit for my Scope ol Construction Proiect (or Descriplion of Work) Projecl Location or Address Name ol Authorized Agent Address of Authorized Aqenl Phone Number ol Authorized Agenl ldeclare under penalty ol perjury that I am lhe property owner lor the address lisled above and I personally filled out lhe above inlormation and certily its accuracy. Property Owner's Signature Dale Print Name ol Owner Note: A copy ol the owner's driver's llcense, lom notarization, or olher verilication acceptable to lhe agency is required lo be presented when the permit is issued to verify the propeny ownet's signature. SANTA ANA CITY COUNCiL 6p!l'do@sanla.ana.oro Mayor Pro Tom, $/ard 2 miman ne2@sanla-ana.oro vsa,m'e.ro@sa.ra.a.a o,o Boloro@sanla-an. or. P. Oav'd Benavdes @Elalrie@l9llt,illrrrc jv'le9as@sada:tui slna'ero@santa-ana.oro Print name of Owner fhntr,-t,t ?t--I ra-2./\,-..--