10194347 - Permit (2) - Laserfiche WebLink

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J/ S. f understand lmay obtain more information regarding my obligations bs an "employer'from the lnternal Revenue Service. the United States Small Business Administration, the Califomia Department of Benefit Payments, and the Califomia Division oI 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. f,]L1 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 and financial res nsib construction activity at the following address .-:V f f . 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. ')J 12.1agree 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. lf you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you wilh any linancial 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 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 musl be completed and signed by the property owner and returned to the agency responsible for issuing the permit. /Vote; A coov of the proDerlv owner's driver's license. form notaization. or other verification table to the re to be ,s ,s to signature. Signature of Property L-Date /0 )- 11 Print name of Owner AUTHORIZATION OF AGENT TO A 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 project. Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent Address 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 oul the above informatjon and certify its accuracy. Property Owner's Signature Dale 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 verily the property owner's signature. SANTA ANA CITY COUNCIL mou do@santa-6m oro Mayor P.o Tem Ward 2 orrunL.ez@sanla ans.oro vsarm'enlolOsanla.ana oro isorono@sanla-ana oro P OavLd Bâ‚¬..sdB dbe.avrdes@sanla-an6 oro giEgas@$!la:@a!g strnaE.o@sanl, sna.oro L