10194384 - Permit (2) - Laserfiche WebLink

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{ L l understand lmay obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of Benelit Payments, and the California Division of lndustrial Accidents. I also understand I may contact lhe California Contraclors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.qov for more information about licensed contractors. G rc.lam aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party Iegally and financially responsible for orooosed construction activitv at the followinq adidress, q)4'6ERN,; 'sf sANlv AfiVA A4 i)7o9 4 't't. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govem Owner-Builders as well as employers. {lZ. I ^gr"" fo 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 nothave 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 court. lt is also important for you to understand that if an unlicensed Contractor or employee of that individual or flrm 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 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. i,lote: A copv of the oropeftv owner's driver's license. form notarization. or other verilication acceDtable to the aoencv is rcquircd to be Dresented when the Dermit is issued lo verify lhe propedv owner's Signature of Property Owner Date tcTo+ 1 t2 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 flle the documents necessary to oblain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Project Location or Address Name 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 filled out the above information and certify its accuracy. Property Owners 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 to verify the propefty owner's signature. PLink ir,rP51 C.unlaiAct r'1\,Assenl) J,Bills N.rl re lo Prii ariv Fornr SANTA ANA CITY COUNCIL moul,do@sa.la-ana do Mayor Prc Tem. Ward 2 m,man nez@santa-ana do siqnature. ' t rt? HdArl/A- Address of Authorized Agent: n