10294006 - Permit (3) - Laserfiche WebLink

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-*--N g I understand lmay obtarn more information regarding my obligalions as an "employer'from the lnlernal Revenue Service, the United States Small Business Administration, the Califomia Department of Beneft Payments, and the Califomia Oivision of Industrial Accidents. lalso understand lmaycontactthe California Contractors' State Liqense Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. a.t I O. 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 financiall res sible for proposed c onstructi at the followinpon rl ('on activih Lloaddress: 4-u,,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. ) t-UZ. I agree to notity the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contraclors are regulated by laws designed to protect the public. lf you contract with someone who does not havea license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. 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 damages. 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 lheir 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. ivote; A coDv of the proDertv owner's driver's license, form notarization. or other verification acceptable to the aqency is required to be presented when lhe permit is issued lo verify the propeftv owner's sionature, Signature of Property Own Print name of Owner , 6 o"t, tol"3l11 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 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 filled out the above information and certify its accuracy. Property Owner's Signature Date Print Name of Owner Note: A copy of the o'^/ner'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 propetty owner's signature. SANTA ANA CITY COUNCIL moulrdo@sanlaâ‚¬na oro Mard Pro Tem. Ward 2 mh3n'nez@sa.Ia ana do samientoAsarb ana do E AqOeSa!&:!!!_!!9 dbenaydesasa.ta-ana oro elleoas@sanb..na oro st,.aâ‚¬roosanta ana orc -z) AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Phone Number of Aulhorized Agent: &