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101100470 - Permit (2)
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101100470 - Permit (2)
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Last modified
11/10/2022 12:10:47 PM
Creation date
11/10/2022 12:10:45 PM
Metadata
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Template:
Permit
Permit Number
101100470
Full Address
2071 S Evergreen St
Permit ID
255030
Master ID Number
2019-151690
Project Name
New Porch Cover
Street Number
002071
Street Direction
S
Street Name
Evergreen
Street Suffix
St
Building Use Code
Resid-1 unit
Job Types
Patio Cover
Permit Type
Building
Applied Date
6/18/2019
Issued Date
9/24/2019
Finalized Date
4/14/2020
Flood Zone
X-0602320276J
Description of Work
New front porch.
Nature of Work
Front Porch
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:;=->t' ff1, I understand I may obtain more information regarding my obligations as an "employe/'from the lnternal Revenue Ser- <br />vice, the United States Small Business Administration.the California Department of Benefit Payments, and the California Divi- <br />sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800- <br />321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />V [Vl lO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />party legally and financially responsible for proposed construction activity at the following ad- <br />dress: . <br />/ N,1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />applicable laws and requirements that govern Owner-Builders as well as employers. <br />1I-MZ I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />haVd provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a <br />license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civtlcourt. lt is also important for you to understand <br />that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held <br />liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and returned <br />to the aqency responsible for issuing the permit. Note: A copv of the propeftv owner's driver's license, form notariza- <br />tion. or other verification acceptable to the aoencv is required to be oresented when the permit is issued to verifv the <br />propertv ow n e r's s ign atu re. <br />Signature of Property Owner Date -2ol <br />t'tTo 0 E <br />Print name of Owner <br />AUTHORIZATION OF AGENT TO ACT ON PROPERry OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my rsonal responsibility, I hereby authorize <br />the following person(s) to act as my agent(s) to apply for, sign, and file the ts necessary to obtain an Owner-Builder <br />Permit for my project. <br />Scope of Construction (or Description of <br />Project Location or <br />Name of Autho Agent: <br />Address of Age <br />P mber of Authorized Agent: <br />I declare under penalty of perjury that I am and I personally filled out the above <br />information and certify its accuracy <br />Property Owner's Signature:Date <br />Print Name of Owner: <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- <br />quired to be presented when the permit is rssued to verify the property owner's signature. <br />property owner for the address listed
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