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SF <br />9. I understand I may obtain more informalion regarding my obligations as an "employer" lrom the lnternal Revenue Service, the <br />United States Small Business Administration, the Califomia Department of 3enefit Payments, and the Califomia Division of lndustrial <br />Accidents. I also understand I may contacl the California Contractors' Stale LicenSe Board (CSLB) at 1-800-321-CSLB (2752) or <br />www.cslb.ca.qov for more information about licensed contractors. <br />SF n.I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />legally and f,nancially responsible for proposed construction activity at the following <br />address:o ?7 <br />lF 't'tll agree that, asthe party legally and financially responsible for this proposed conslruclion activity, lwill abidebyall <br />applicable laws and requirements that govem Owner-Builders as well as employers. <br />][t Z. t "gr"" to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lfyou contract with someone who does not havea license, <br />the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. <br />Your only remedy against unlicensed Contractors may be in civil court. lt isalso important for you to understand that if an unlicensed <br />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 <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are <br />properly licensed and the status of their workers' compensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the <br />agency responsible for issuing the permit. IVote; A coDy ol the Dropeftv owner's driver's license. form notarization. or other <br />verification acceptable to the aqencv is rcouired to be presented when the permit is issued to verifv the propeftv owner's <br />siqnature. <br />owner - Sfur. 1a*tt-.'Date 6.2.e. /7Signature of Property <br />Print name of Owner A4?a{/E RtRtaN<-.. <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the <br />following person(s)to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description of Work) <br />Name of Authorized Agent <br />Phone Number of Authorized Agent <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally fllled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required lo <br />be presented when the permit is issued to veify the propefty owner's signature. <br />PL rn k.$J P51 /C ou nte.Activity,Assenr L,lyBrlls Notrce to Property Forn'l <br />SANTA ANA CITY COUNCIL <br />moul'do@$nta{n. do <br />Matlr Pro Tem Wa.d 2 <br />oirurl nez@sant.-3.a do <br />V6re Samisro <br />6ampnto@santa€ne m Ed!!gell!la:@a-ar9 <br />P Davd B6nsvd6 <br />db€navd6@sant3.ane oro MllMs@senra-ana oro sr na€ro@sa.ta-am oro <br />Project Location or Address: <br />Address of Authorized Agent: