20164234 - Permit (2) - Laserfiche WebLink

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.( WS. I understand I may obtain more information regarding my obligations as an "employer" from lhe lnternal Revenue Service, the LJnited States Small Business Administration, the Caiifornia Department of Benefit Payments, and the Califomia Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.aov for more informalion about licensed contractors. /t - tO. t 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 address: respo nsible for proposed constructio vl at the followi 4q4 ?2?27tf -=. .u, applica 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all ble laws and requirements that goyem Owner-Builders as well as employers. ^!rr. I agree to notify 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. lfyou contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a com plaint. Your only remedy against unlicensed Contractors may be in civil courl. lt is also important for you to understand that if an unlicensed Contractor or employee ofthat individual or flrm is injured while working on your property, you maybeheld liable fordamages. 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 propedy licensed and the status 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 pe rmit. /Vole.' A coDv of the Dropertv owner's driver's license. form notarization, or other verification acceptable to the aoencv is required to be presented when the Dermit is issued to yerifu the propertv owner's sionature. Signature of Property Owner Date: ?- 45- 2Atl Print name of Owner 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 file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Project Location or Address ;/+crl 727O7 Name of Authorized Agent: Address of Authorized Agent:o.) Phone Number ot A uhonzed Agent: 7 /4 - q/4 - /.. 4; /5 + I declare under penalty of pe4ury that I am the ro erty owner for the address listed above and I personally fllled out the above information and certify its accuracy Property Owner's Signature 742 Print Name of Owner Note: A copy of lhe owner's diver's license, form notarization, ot other verification acceptable to the agency is requied to be presented when the permit is issued to verify the propefty ownet's signature. PL n k:!! P51 /C ounterActrvrty AssemblyBills, Nolrce lo Property Form SANTA ANA CIIY COUNCIL flA A rz/,4.'Usi t<aU,'*- moulrdo@s3ota-ana.oro M:yor Pro Tem. w8rd 2 m menine26sanle-anE oro V'.e.re Samienro lsa.mrenro@santa-a.a oro Dplsis@!!ds.e!!j!9 P Oavd Benav,des dbenEudenosanla'ana oro i![e$!@$!.lria!a-crg slrnaâ‚¬ro@sa.ta-sna oro oate: ?-8C-2O/7