10194398 - Permit (2) - Laserfiche WebLink

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-$fundersrand I may obtain more informalion regarding my obligalrons as a.n employer" from the lnternal Revenue Service. the United States Small Business Administratron. the Califomia Deparlment of Beneflt Payments, and the Califomia Division of lndustrial Accidents.'l also 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. J/ 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally a address ndfi an ia ll yre onsibl <1 e for proposed construction a at the following q * l. 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. S-Zlz. t 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 resull of a com plaint. Youronly remedy against unljcensed Contractors may be in civil court. lt isalso important for you to understand that if an unlicensed Contractor or employee ofthat individual or firm is injured while working on your property, you may be held 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 properly licensed and the status of their workers' compensation insurance coverage. Beforo 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. Notei A copv of the propeftv owner's driver's license. form notarization, or other verification acceptable to the aqency is rceuired to be prcsented when lhe permit is issued lo verify the propely ownets sionature. Signature of Property Print name of Owner Owner Date AUTHORIZATION OF AGENT TO AC T 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 llle the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of work) Project Location or Address 0-u- / > *.< Name of Authorized Agent Address 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 certify its accuracy. Property Ownef 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 to verify the propefty owner's signature. PLinkr\',iP51 Co!.t'rAciLr t! A-cseml)l,E lLs l'.loi,te to PrL\;,C.iY Foii.ir SANTA ANA CITY COUNClL nrou rdo@$nla-sn3.oro M.yo. Pro rem, Ward 2 m manrnerrosanra-ana oro E!rp!@$.dE!r-ea P Oasd Eenaudes dbe.av'des@s6ntEâ‚¬na oo M eo6s@s6nta-ana oro srrna6ro@sanla.ena orovsarm enro@san13 an3 oro .-) Phone Number of Authorized Agent: _