10193976 - Permit (2) - Laserfiche WebLink

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9. I understand I may obtain more information regarding my obligations as an "employer" Irom the lnlernal Revenue Service, the 4k ro. r lEsally ano address: am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party financially responsible for proposed construction activ ity at the following/3o 70 {V 't't.l agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements thal govem Owner-Builders as well as employers. 4L'tr. ragree to noti, 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 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. Youronly remedy against unlicensed Contractors may be in civil cou(. lt isalso important for you to understand that if an unlicensed Contractor or employee of that individual or firm 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 slgned by the property owner and returned to the ency responsible for issuing the pe rmit. Nofe.' A coDv of the Dropertv owner's dri license, form notarization, or other rification lable to the nc ,s re uired to be sented when the rmit is issued to the lure. Signature of Property Print name of Owner Owner Date AUTHORIZATION OF AGENT T A CT 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 file the documents necessary to obtain an Owner-Builder Permit for my prorect. AlDla<- 4eao 2, - c 44 D E-'7t4.! rtc> z. 44la,r.Z- Scope of Construction Project (or Description of Work)J parro ,--> / a4o + "t.n a*R Project Location or Address 21ta t2Aalto 6 AlE . -i4at rtt A-t 4 4-t l2z Name of Authorized Age nt: /-r z A*ta FteucaoA Address of Authorized Agent /ooa /6 /4 Phone Number oI Authorized Agent: I declare under penalty of perjury that I a the pro n66liluddru"" tisted above and I personally filled the above information and certify its accuracy 5Property Owner's Signature Date Print Name of Ownerl Note: A copy of the 's driver'licen no rization, or other verification acceptable to the agency is required to be presented when the permit is issued to veify the propefty owner's signature. PLr.k:'rrrP51 Ccun ie rActivity. ASScmbl) B ills Notice to Propedy Fo.m SANTA ANA CITY COUNCIL mool'do@sa.ta-6na do MEyo. fto I6m. WErd 2 mrtunrnez(asanra-am m V cenre $mLe.to vsad enro@sanra-aG.do Eplge je!3d!.!!!_A!g dbenaed.s6sa.ra'ana o.o ru e.as.Asanta-a.a oro slL.areroasanG-sna oro United States Small Business Administration, the California Department of Benefit Payments, and the California Division of lndustrial Accidents. I 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. l-