10294927 - Permit (2) - Laserfiche WebLink

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'lK S. I undersland I may obtain more information regarding my obligationF as an "employer" Irom the lnternal Revenue Service, the United States Small Business Administration. the Califomia Departm'ent of Benefit Payments, and the Califomia Division of lndustrial Accidents. I also understand I may contact the California Contraclors State License Board (CSLB) at 1-800-321-CSLB (2752) or wra/w.cslb.ca.oov for more information about licenseb contractors. 'lK n.l 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 address: 16 I I . 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. fi12.1 agree 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 unabletoassist youwith any flnancial loss you may sustain as a result of a com plaint. Youronly remedy against unlicensed Contractors may be in civil court. lt is also imporiant for you to understand that if an unlicensed Contractor or employee ofthat individual orfirm is injured wtrile working on your property, you may be held liable for damag es. lfyou 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 signed by the property owner and returned to the agency responsible for issuing the permit. Ivore.' A copv ol the proDeftv owner's drivet's license, form notarization. or other verification acceptable to the aqency is required to be prcsenled when lhe permit is issuCd lo verify /ihe prepeftv owner's siqnature. Signature of Property Owner Date r --..-2-Print name of Owne r /tlO l{ni / t AUTHORIZATION OF AGENT TO AC T 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 flle the documenls necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) 7 Project Location or Address 7121 /4/'ao+)e"ra ),o (c', 2z rt 75'a Name of Authorized Agent:4-no, - Address of Authorized Agent:_ Phone Number of Authorized Agent ;/-7 3-2 I declare under penalty of perjury that I am the property owner for the address listed above and I personally fllled out the above information and certify its accuracy --78 K^:*4Property Owner's Signature Date: 11 -.V-'1 7 Print Name orowne ,t -i6 KA ,urZ , Note: A copy of the tetolhe agency is required to be presented when the permit is issued to verify the propedy owner's signature. PLrok \/\/i51'Ccuni,:rAclrrrir Asscmbly6 ls l.l1,trce to ProDe(y Foinr SANIA ANA CITY COUNC L moul'd06sanla-ana oro Mayor Pro Tem, Ward 2 mr6a n .e26sanla 'ana oro Vlcenle Sâ‚¬rm'enlo Bamâ‚¬nloasenIa ana oro Ed!!!(!$!hir!!-p!c P Davrd Bâ‚¬navrdâ‚¬s dbenaudeslosanla-ana oro Mlleo6s@sanl,.a.a do srinaâ‚¬rc@sanla-ana do