10291284 - Permit (2) - Laserfiche WebLink

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1/ -/1/KLs. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the' Unitbd States Small Business Administration, the California Department of Beneflt Payments, and the California Division oI lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 'l -800-321-CSLB (2752)or lb.ca ov for more information about licensed contractors ally 10. I am aware of and consent lo an Owner-Builder building permit applied for in my name, and understand that I am the party and financially responsible for proposed construction activity at the following add 1 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all ap ble laws and requirements that govern Owner-Builders as well as employers '12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have p ded 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 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 damag es. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifi/ing whether or not those Contractors are properly licensed and the status of their workers' compensalion insurance coverage. Bofore 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. Nofe;of the owner's driver's licen verification acceptable to the aaencv is reouired to be presented when the permit is issued to vetifv the propertv owner's siqnature. Signature of Property Owner Date 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 lile the documents necessary to obtain an Owner-Builder Permit for my project. Scope cf Construction Project (or Description of Work) Address of Authonzed 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 filled out the above information and certify its accuracy. Property Owner's Signature Date Print Name of Owner: Note: A copy of the owner's driver's license, form notarization, or other yerification acceptable to the agency is required to be presented when the permit is issued to verify the propefty owner's signature. SANTA ANA CITY COUNClL moo do@sEnla-a.a oro Mayor Pro Iem Wa.d 2 mrmanrnez@sanIa ana oro vsarnrenro@sanra-a.a oro P Davd Senavrdes dbenav des@sa.la ana oro strna erolosanla s.a oro Printnameorowne, y'fttZV L*t POect Location or Address: Name of Authorized Agent: Edgqo$da.@a-o!9