10194276 - Permit (2) - Laserfiche WebLink

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Nli 9. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of Beneflt Payments, and the Califomia Division of lndustrial Accidents. lalso understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.oov for more information about licensed contractors. Nt, tO. l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that l am the party legally and financiall address: sible rp ropo sed con ctio activity at followi Y,l <tzl cAt4na \r/ tL tagree that, asthe party legally and financially responsible for this proposed construction activity, lwill abidebyall applicable laws and requirements that govem Owner-Builders as well as employers. !(t2. t ,gr"" 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. lf you contract with someone who does not have a license, the Conlractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a com plaint. Youronlyremedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed Contractor or employee ofthat individual orfirm is injured while working on your property, you maybeheld 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 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 permit. ,Vole.' A coov of the prooertv owner's driver's license, form nolarization. ot other verification acceDlable to the adencv is reouired to be Dresented whe n lhe Dermit is issued to verifv lhe Drooertv owner's siqnature.-t' Signature of Property Owner Dale t Print name of Owner N 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 flle the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent 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 certity 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 verification acceptable to the agency is required to be presented when the permit is issued lo verify the propefty owner's signature. PLink.vll P5 1'Ci,unl.JrActivriy,Ass.enri)1,/B I s N!irce tc Prr,Deriv Forn SANTA ANA CITY COUNCIL mouhdorAsanlE Ena.o.o Mayor P.o Tem Wa.d 2 mrmanr.ez@sanla anaoro vrcenle Sam,c.lo vsarm'enbras3nla-Ena.oro Bolono,Osa.â‚¬-ana do P Oaed Bâ‚¬naedes dbenavtdes@sanla-3na.oro !y!eg3s@i3!]3.!!3.9!9 sl'narerorA sanl! ana oro I AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF