30138263 - Permit (3) - Laserfiche WebLink

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licensed subcontractors and the number ol structures does not exceed lour within any calendar years, or all of the work is performed under contract with a licensed general building Contractor. B--LU I understand as an Owner-Builder if I sett the property lor which this permit is issued, I may be held liable lor any financial or personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the workmanship or materials. Bj-r. I understand I may obtain more inlormation regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the Calilornia Department of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contacl the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. 8-1,1 '10. I am aware of and consent lo an OwnerBuilder building permit applied for in my name, and understand that I am [", ligF "i5'l Y ^gw E"J"['i# faUp*&? "VE\IH" Hn f^' "t*' 2 * q t, t o,t 6-nd 11. I 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 OwnerBuilders as well as employers. O-A" I agree to notily the issuer of this form immediately of any additions, deletions, or changes lo any of the information I have provided on this Iorm. Licensed contractors are regulated by laws designed to protect the public. ll 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 ol 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 lirm is injured while working on your property, you may be held liable for damages. ll 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 lhe status ol 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 lor issuing the permit. /Vole.' A copv ol the orcoertv owner's driver's license, form notarization. or other verilication ecceDte ble to the aoencv s reouired to be senled when the Derm s issued to verily the owner's sionature. Signature of Property Own I )ts {4/oT4 Date 03-ot prinrnameor o*^",,P,8/ AS lt/ oTV AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, lhe execulion ol which lunderstand is my personal responsibility. I hereby authorize the following person(s) lo act as my agent(s) to apply lor. sign, and,ile the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Project Location or Address Name ol Authorized Agenl Phone Number of Aulhorized Agent ldeclare under penalty of perjury thal I am the property owner for the address listed above and I personally filled out the above information and certily its accuracy. Property Owner's Signature Date Print Name ol Owner Note: A copy ot the owner's driver's license,lorm nota zation, ot other verilication acceptable to the agency is required to be presented when the permit is issued to verity the propetty ownet's slgnature. SANTA ANA CITY COUNCIL nel'.io@Fnla-ana.oro Mayor P.o Tem, Wad 2 mtunnâ‚¬r@snra ana cro slono@sanla.ana.oro P Oavd Benavdâ‚¬s t!e!rsd9@raqr:a!r,sc ,, eoas@sa1ra .' a o'o sr ld'e o(asdnra a.a o'. Address ol Authonzed Agent: