10293046 - 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 perlormed under contract with a licensed general building Contractor. v! \ 8 I understand as an Owner-Builder if I sell the propeny lor which this permit is issued. I may be held liable lor any finahcial or personal injuries sustained by any subsequent owne(s) that result from any latenl construction defects in the workmanship or malerials. A'1 S. t understand I may obtain more informalion regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the Calilornia Department o, 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.qov for more information about licensed contractors. J0. I am aware of and consenl to an Owner-Builder buildin g permit applied for in my name, and understand that lam the le lly and financially resp onsible for osed construction activi at the Iollowi ngro address ty hra.-,l 1 I agree lhat, as the party legally and financially responsible for this proposed construction activity, I will abide by all apllicable laws and requirements that govern Owner-Builders as well as employers. &<12. I agree to notity the issuer ol this lorm immediately ol any additions, deletions, or changes to any ol the infordation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public- lf you conlract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any linancial 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 lor you to undersland that i{ an unlicensed Contractor or employee of that individual or firm is injured while working on your properly, you may be held liable lor 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 the status of their workers' compensation insurance coverage. lorm notarization, or other veritication acceptable to the aqency is required to be presented when the permit is to veri L t Signature of Property Owner Date Print name ol own"a4 S \v1 â‚¬"v+<1 AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice lo Property Owner. lhe execution ol which I understand is my personal responsibility, lhereby authorize the following person(s) to act as my agent(s) to apply for. sign, and file the documents necessary lo obtain an Owner-Builder Permit for my project. Scope of Construction Projecl (or Description of Work) Project Location or Address Name ol Authorized Agent Address of Authorized Agent Phone Number of Authorized Agent ldeclare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above inlormalion and certjfy ils accuracy. Date Print Name ot Owner Note: A copy ot the owner's driver's license, torm nolarization, or olher veritication acceptable to the agency is required to be prcsented when the permit is issued to verity the propetly owner's signature. SANTA ANA CITY COUNCIL nx)ulrdo@snre.ana oo Mayor Pro Tem, Wa.d 2 ft nan!ner@s.nta.af a.o.o VLcenre Samenlo vsm6nlo@snta-ana.rc Eororo@sanla.ana oro llSljirl:jil.!.all &!99rr@!i!b:a!r,q9 Betore a building permit can be issued, this lorm must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A coDv of the propertv owner's driver's license, P'operly Owneas Signature: