30138265 - Permit (3) - Laserfiche WebLink

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licensed subcontraclors and the number ol structures does not exceed four within any calendar years, or all of the work is erformed under contract wilh a licensed general building Contractorp na cra o understand as an Owner-Builder il I sell the property lor which this permit is issued, I may be held liable for any r personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by ble laws and requirements that govern Owner-Builders as well as employers. WO manshi p or malerials I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, lhe California Department of Benefit Payments, and the California Division ol lndustrial Accidents. I also understand I may contacl the California Contractors' State License Board LB t 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. I am aware of and consent to an OwnerBuilder building permit applied lor in my name, and understand that I am legally and financially responsible for proposed construction activity at the following address h ep ca (l *f ^n "" r"notity the issuer of this lorm immediately of any additions. deletions. or changes to any ot the f,lffig/on i have provided on this rorm. Licensed contraclors 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 resull of a complaint. Your only remedy against unlicensed Conlractors may be in civil courl. lt is also important for you to understand that if an unlicensed Contractor or employee ol that individual or firm is injured whlle working on your property, you may be held liable for damages. lf you obtain a permit as OwnecBuilder 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. Betore a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. A/ote.' A coDv of the DrcDertv owner's driver's license, torm notarization, or other veritication acceptable to the a oencv ,s reouired to be Dresented when the Dermit is issued to verifv the Dropertv owner's sionature. Signature of Property Owne Print name ot o**-Il?^ /-t -P /a.^,lA^' - Date 6 \/\A -) v'1 a-)\f \.-7 AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner. the execulion ol which lunderstand is my personal responsibilily. lhereby aulhorize the following person(s) to act as my agent(s) to apply for. sign. and file lhe documenls necessary to obtain an Owner'Builder Permit,or my Proiect ;zo^1T oF Scope of Construction Proiect (or Description of work)2E/t.rc//,Z 6c u+-,2 /t^rL - lo rttâ‚¬ zt s h/ac K- Proiect Location or Address /o /0 S, DrUrTt .rortr) On-gqlurq 4da I -lZzo-l Name o, Authorized Agenl BoABtL l""nar' tD4r-ztnn") Phone Number of Aulhorized Age nt: 7/ / "2-i 4<q L ldeclare under penalty ol perjury th m lhe property owner for lhe address lisled above and I personally filled out the above inlormation and cerlify Property Owner's Sign Print Name of Owner: its accura alure s Dare: 7 -b'/ 2 /yl Note: A copy ol the drivet's llcense, torm notarization,verilication acceptable to the agency is required to / 6oo o'7 be presented when the permit is issued to verily the propetty owner's signatute. SANTA ANA CIIY COUNCIL r.Euhdo@sanh-ana.oro rvlayor P.o Tem. Ward 2 mnlanr.ez@san!a ana.oro Vrcentâ‚¬ Samenro vsamsnlo@santa.ana.orc 60rono@s.ra'ana.oro P Oav,d Benavdes @9qrv!dr5@!oh:a!rr!9 o llecas@sanra.ana o.o srinaâ‚¬ro@$nra-ana oro t4 n v 4 L 7 Address or Authoriz ea asentt (otL 3.r,. DZt â‚¬/z-z ooD ,D rz 3.4 . C. l7)a-/