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SepnT DA17 3 28'39 PM berenyiaw 818 789 9041 <br />/-<\ <br />[dlr. , uno"r.,"nd I mty obl8in mor! informauon rBgardlng my obllgElion! ss sn'Employer hom ih8 lntrrnal Ravrnu€ servtce, tho <br />UJdited Slatoe Small BuBlnssB Admlnlslratlon, hs CallfornlE Depsdment of Elsnoilt PEymrntE, and the Callicmla Divigion of lnduEElal <br />Accldents, lrlEo und.r8t d I m8y mntAci the C8lltomiE Cor raclors' State Llcen3o Bosrd (CSLB) at 1{00-321.CSLB (2752) or <br />for morr lnformEtlon Ebout llcBneed contrgolorg, <br />ally <br />'10. I am awrre of Bnd consent to an Ownor-Bullder building p6rmh lppll6d for ln my nam6, and undarstand th8t t am lh€ party <br />ond llnancislly ro8ponElble for proposcd conrtructlon ac,tlvlty 8t lho follorvin0 <br />ss <br />1 1. I Egroe th8t, ts Ih€ psrty lagally end finsnol8lly rsEponElblo for thl8 prcpooed constructlon actlvlty, I wlll sblde by all <br />! lawE and rugulrcmenlE thot govom Orvnsr-Bullder! at woll ,8 Bmploy8 B. <br />I sgrcs to noufy th€ lrsuer ot iil3 lorm Immedlrtety of any rddltions, dolsUons, or chsng68 lo Bny of th0 Informrdon I hsvs <br />on thi6 form. <br />LlcsnEM contsactor6 arE rogulatM by lEwr ds8lon6d lo protecl tho public, lf you contract wlth Eomeon€ who dooS not have a llcsnEs, <br />thB Contrsclor!' Slalo Lio€nr€ BoErd may br un!bb to rEEiEl you wllh Bny flnanclal loss you mcy suEtlin rs I rc6ult ot r complalnt. <br />Your only r€medy EgBlnBt unllcenled Contrsctors may b€ ln clvil coud. ll ls also lmportant tor you to lnd6rst8nd thSt il En unllc€ns€d <br />Conlrector or Employoo of that lndividual or firm ls lnjursd '.rhllB lvorklng on your property, you mgy b€ hsld llEblc for drrnago0. lfyou <br />obt6ln B permlt aB O\rn6r€ulld6r and v/Bh to hlre Contactors, you will bB rr8ponsiblB for vcrlfylng lvi€ther or nol lhoEe Con6ctort 6rc <br />proplrly llclnsld rnd thc itrtua olihcir work!46 @mpen6atlon hsulancE covorage. <br />BefioIr ! bulldlng pormlt csn b9 lriued, thls lorm must be colhplotsd end rlgnEd by thc p.oprrty owner and mtumed to ths <br />agency rceponsiblr for i$ulng $€ pormlt, Nolo: Acoiv of ha propcttt owne/. drlvclt llc.naa, tonn not ir.tlon. or olhet <br />vo fic.llon rcco,tahle tqllJe adency lF noulrsd lo be pn0cnled whan lhc aemll k lgsuad lo ve fu the otooorlv own.rtr <br />,E/gnature. <br />SlgnEturB ol Prop€rty Orf1er 7 -a -t] <br />Print n8me of o-nc,-b tt *fua \, lltl*r I *-, lk(+lr*,- fut h u, tz (fi ffi .*t/n\ <br />ttc' ) <br />AUTHORIZATION OF AOENT TO ACIIN PBOPERTY OWNER'g BEHALF <br />Excludlng th6 Notce lo Pmpsfty Olvnor,lhc exoqutlon of whlch I under6trnd 18 my p8rBon8l reEponslbtllv, I h6reby <br />follovring psrEon(s) 10 rct as my agon{8) to apply hr, 819n, and fil€ tho documBnts nscassary to obtaln an owner-B <br />projaot <br />authorlzs the <br />ulld€r Psrmltror my <br />Scope ot Conahrcllon Pmlect (or Delciptlon of Work)ffi07-zc11X <br />Prolect LocEtlon or AddrBss:7)olc'). t(,0n:./4.,S,t-r* A-a <br />Nams of Aulhorized Agent;f+*^s (* <br />AddrgEr af Authorizrd Agonl <br />Phone Numbor ofAuthorizod Ager{i >/,/-za +q6 <br />ldeclrre undrr prnally ofpcrlury thEt I am the property owner for the addrEss llstod Ebovo rnd I per8onslly llllsd out lhe rbov€ <br />informatjon 6nd ceftily lt. accursq,oao;?.?2-t7Prap!rty Own€r's SignPturE: <br />Prlnt NEmB of OwnEr:t*tt <br />llolei thc etree,lorm nottrlu or othct e.rlllcetlon eccgptrbrg lo the ,gency ls Nqulnd to <br />bq p.e'en pcmlt lE au thq prgp.tty owh.fe slEnaturc. <br />PLlnk:W P51 /CountorActlv,ty/AsssmblyBills/Nolico to Property Form <br />SANTA ANA CITY COUNCIL <br />\ <br />Eu!aluaa&!..-q &.dlgiErtdulri!It!@l!!,trlnrlcar.E [da.E !!ar!!,s dFr.!ritarr.{m@ dlr3$44dl,.0r.@ !rriiJ6+u''{ d!