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_/1 <br />1-fl6' understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Ser- <br />vice, the United States Small Business Administratlon, 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 iZISZ) or www.cslb.ca.qov for more information about licensed contractors..({-a <br />\ 'F \d'l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />partyTegally and financially responsible for proposed construction activity at ihe following ad- <br />I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />laws and requirements that govern Owner-Builders as well as employers. <br />2.1 notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />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 civil court. 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 agency responsible for issuing the permit. Note: A copv of the propeftv owner's driver's license. form notariza- <br />propettv ow ne r's si q n atu re. <br />re of Property Owner <br />Address of Authorized Agent: <br />Date lZ-10't? <br />CL, OPrint name of Owner <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize <br />the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder <br />Permrt for my project. <br />Elec+r,'<.4 \ \.*, oScope of Construction Project (or Description of Work) <br />Project Location or Address 3 0l 5 tf f". Au*roil^llo J^ <br />d*r." of Authorized Agent.0o Lqt' <br />Phone Number of Authorized Agent:7oZ-Ze o-L{o7 O <br />I declare under penalty of perjury that I am <br />information and certify its accuracy <br />Property Owner's Signature: <br />for the address listed above and I personally filled out the above <br />z. <br />Irr,n, Name of owner:h5(/ <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 rs issued to verify the property owner's signature.