20170746 - Permit (3) - Laserfiche WebLink

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-!-5. I understand I may obtain more information regarding my obligations as an "employef'from the lnternal Revenue Ser- vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California DivF sion of lndustrial Accidents. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at'l-800- 321-CSLB (2752)or www.cslb.ca.qov for more information about licensed contractors / lO.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 flnancially responsible for proposed construction activity at the following ad- dress: / ,a .l 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. / lZ. I agree to notify the issuer of this form immediately 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. 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 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 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 issuin the permit. Note: A copv of the DroDertv owner's driver's license, form notariza- ac the it is issued to the proDertv owner's siqnatu re. Signature of Property Owne >l ,LO Date Print name of Owner frrcuq I'l oil o r-i AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, lhe 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)fuA sLcr)< )& D@, 3-)o tJ fuk * 5zn4- ,4,r, cA Name of Authorized Agent:/{a.yutr{l A,ilonra^ Address of Authorized Agent )ttt tD {5t ST +'^ 5ov}4- A*. CA q4q-U* - olato I declare under penalty of perjury lam e property owner for the address listed above and I personally fllled out the above information and certify its accura Date: i '1 \LO Print Name of Owner:t\o1l 4c't- Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is rc- quired to be ptesented when the permit is issued to verify the propefty owner's signature. Project Location or Address: Phone Number of Authorized Agent: I Property Ownels Signature: t