Laserfiche WebLink
-( 9. I understand I may obtain more information regarding my obligations as an "employer" Irom the lnternal Revenue Service, the <br />United States Small Business Administration, the California Department of Benefit Payments, and the Califomia Division of lndustrial <br />Accidents. lalso understand lmayconlactthe Calilornia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or <br />www.cslb.ca.oov for more information about licensed contractors. <br />rtf- 10. Iam aware of andconsenttoan Owner-Builder building permit applied forin myname, and understand that Iamthepafty <br />legally and financially responsible for proposed construclion activity at the following <br />address: <br />r t, 1 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />applicable laws and requirements that govem Owner-Builders as well as employers. <br />!L12. I agree to notifr/ the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, <br />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. <br />Youronly remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed <br />Contractor or employee ofthat individual orfirm is injured while working on your property, you may be held liable for damag es. lfyou <br />obtain a permit as Owner-Builder and wish to hire Contactors, you ,,vill be responsible for verifying whether or not those Contraclors are <br />properly licensed and the status of their workers' compensation insurance coverage. <br />Beforo a building permit can be issued, this form must be completed and signed by the property owner and returned to the <br />agency responsible for issuing the permit. ,Vote : A coov of the DroDertv owner's driver's license, form notarization. or other <br />verification acceDtable to the qencv is reouired lo be oresenled when the Dermit is issue to verify the propertv owner's <br />siqnature. <br />Signature of Property owner 1fr"",a tb Date <br />Print name of Owner -CANa--J]0 <br />Project Location or Address <br />Address of Authonzed Agent; <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner: <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to <br />be presented when the permit is issued to verify the property owner's signature. <br />SANTA ANA CITY COUNCIL <br />mpuhdo@sant -ana.oro <br />Mayo. Pro Tem Ward 2 <br />mrmEninez@sanlE-aoa do <br />Vi@.le $mienlo <br />6emrento@sanla-ana o.o 60lonoasanlaa..oro dbanavrdesaasanla-ana.oro rsl&98@!,a!E:a4a-arq sl'rsrero@sanla ana oro <br />AUTHORIZATION OF AGENT TO ACT ON PROPERW OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I undeBtand is my personal responsibility, I hereby authorize the <br />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 <br />prolect. <br />ScopeofconstructionProject(orDeScriptionofwork); <br />Name of Authorized Agent; <br />Phone Number of Authorized Agent: