30241953 - Permit (2) - Laserfiche WebLink

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I understand I may obtain more information regarding my obligations as an "employe/'from the lnternal Revenue Ser- ce, the United States Small Business Administration, the California Department of Beneflt Payments, and the California Divi- sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800- 321 SLB (2752) or www.cslb.ca.qov for more information about licensed contractors aiy eg . I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the ally and financially responsible for proposed construction activity at the following ad- dress I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicabplans and requirements that govern Owner-Builders as well as employers. .Nt}lr tI\ 2. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the rnformation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone 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. lt is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is in.jured 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 verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Signature of Property Owner Date: J'1a zfr Print name of Owner a AUTHORIZATION OF AGENT TO ACT ON PROPERW OWNER'S BEHALF Excluding the Notice to Prope(y 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. Project Location or Address Name of Authorized Agent:/-rrrrl, 4.";/lo Address of Authorized Agent: Phone Number 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 Property Owner,s Signature Date J 4 print Name of own"r. /27a'/l/r- /o /., H."y' Note: A copy of the owner's drivels license, form notarization, or other verification acceptable to the agency is re- quired to be presented when the permit is issued to ve fy the propefty owner's signature. Before a building permit can be issued, this form must be completed and signed by the pioperty owner and returned to the agency responsible for issuing the permit. l/ote.' A copv of the propeftv owner's driver's license, form notariza- tion, or other verification acceptable to the aaencv is rcouired to be presented when the permit is issued to verifv the p roDertv owne r's sion atu re. Nv-,- ScopeofConstructionProject(orDeScriptionofWork)