20164398 - Permit (2) - Laserfiche WebLink

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./ f\LV , understand lmay obtarn more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the Califomia Department of Benefit Payments, and the California Division of lndustrial Accidqnts. lalso understand lmaycontact the California Contractors' State License Board (CSLB) al 1 -800-321-CSLB (2752 ) or www.cslb.ca.qov for more information about Iicensed contractors. l\', O , 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 financially responsible for proposed construction activity at the following addresy iluY,. I agree that, as the party legally and financially responsible for this proposed mnstruction activity. I will abide by all e laws and requirements that govem Owner-Builders as well as employers.applicall at_v frovided I agree to notify the issuer of this form immediately of any additions, deletions. or changes to any of the information I have on this form. Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does nothavea license, the Contractors' State License Board may be unable to assisl you with any financial 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 ofthat individual orfirm is injured while working on your property, you may be held liable for damages. lfyou obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verii/ing whether or not those Contractors are propedy licensed and the status of their 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.Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the asency is required to be presented when the permit is issued to verify the property owner's sionatute- Signature of Property Owner AfitilA LvALr trTrv t-fl Date h VA M AUTHORIZATION OF AGENT TO ACT 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 peBon(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 out the above information and certiry its accuracy. Property Owner's Signature Date Print Name of Owner: Note: A copy ot 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 fo verify the property owner's signature. SANTA ANA CITY COUNCIL mouldoi@$nt -ana do 6arh'enb@sanla-ana oro 6or@o,Asanra -ana .*o dbenav'des@sanla-ana oro rM easasanta a.a oro shnasolAsanta r.a.oro Print name of Owner -tI M'cher. Ma.lle2 Mayor Pio Tem Ward 2 mrronrnez6santa-ana o.d