10294904 - Permit (2) - Laserfiche WebLink

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m-9. I understand lmay obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service. the United States Small Business Administration, the Califomia Department of Beneft Payments, and the Califomia Division of lndustrial Accidents. I also understand I may conlact the Califomia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. ffi- ,lO , am aware of and consent to an owner-Builder building permit applied for in my name. and understand that I am the party l?ffi,"sB*:er,?:"',ff*:,x"Jlf?""-"{?n,:,,ulx5{,,"H;"4, A rz ?o+ N1 , agree that, as the party legally ano financiatty res/onsible for this proposed construction activity, I witt abide by att apP|lr,able laws and requirements that govem Owner-Builders as well as employers. -[r 2. , ,gr"" ,o 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. lfyou 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 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 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 Contacto6, you will be responsible for verifying 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. Notâ‚¬A coov of lhe Drooertv owner's license, form notarization, or other verification acce table to the ,s re uired to be he d sionature, Signature of Property Own Date: t I /-,+It+ Print name of Owner fR-4,.\n aurxontlArtoN oF AGENT To Acr oN pRopERTy owNER's BEHALF Scope of Construction Project (or Description of Work)V,"*4* tl, n&urs Project Location or Address 1-oLd S. G-y<tt:V,"- ) ea.^jn fu^G 4 zl,t0 1r'1 Name of Authorized Agent Address of Authorized Agent I declare under penalty of perjury that I information and certify its accuracy. the prope owner for the address listed above and I personally fllled out the above Property Ownels Signature Print Name of Owner:\ YAzwt Note: A copy of the owner's driver's licen form notarization, or other verification acceptable to lhe agency is required to be presented when the permit is issued to rify the property owner's signature PLink:WP51/CounterActivity/AssemblyBills/Notice to Property Form SANTA ANA CITY COUNClL Mayor Pro Tem. Ward 2 moulrdo@santa-ana qo sl naero@sanl.a ..a do 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. Phone Number of Authorized Agent: our", lf z-tl17-