10193567 - Permit (3) - Laserfiche WebLink

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-[.1S. f understand I may obtain more informalion regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the Califomia Department of Beneflt Payments, and the Califomia Division of lndustrial Accidents. lalso understand lmaycontactthe Calilornia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.oov for more information about licensed contractors. 10. 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 financially responsible for proposed construction activity at the following address , D/,.I agree that, as the party legally and linancially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govem Owner-Builders as well as employers V/ 12.I agree to notity 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 assisl you with any linancial loss you may sustain as a result ol a com plaint. 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 maybe held liable for damag es. 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 slatus 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 issuing the permit, ivote: A copv of lhe prcpertv owner's driver's license, form notaization. or other verification acceptable to the y is reouircd to be Drcsented when the permil is issued to verifv the Drooertv owner's Signature of Property Owner D@{u."o",", ? [ Zo Print name of owre, C) C> \ orc.; AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property 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 Ille the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) >â‚¬tz--..-.---<_.--\ S LosProject Location or Address Name of Authorized Agent 'lrn 7a 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 fllled out the above information and certify Property Owneas Sign its accuracv- ".\ ./ I Date -l ,0 t Print Name of Owner Note: A copy of the o s driver's lic be presented when the permit is issued to verify the property owner's signature,,: SANTA ANA CIIY COUNC L () P O.ed Eenaedos dbenavdB@sanra-ena o.o rvffr!!se!3!]!.i!!- sr na'eroO sarl.'ana o'o se, form notarization, or other verification acceptable to the agency is required to mouldo@sEnl,-aFa no Mat r Pro Tem, Ward 2 m'man nezlasanla-ara do Ed.a!.q@5t!Eia!!-e!c sionature. 1t