10194632 - Permit (2) - Laserfiche WebLink

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,, ,1 1: 9 I understand I may obtain more information regarding my obligalions as an "employer'from the lnternal Revenue Service, the United States Small Business Administration. the Califomia Department of Benefit Payments, and the Califomia Division of lndustrial Accidents. I also understand I may contact the Calirornia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or for more information about licensed contractors 10. 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 flna re ble for pro ction acti the followingconsoonstw ":-rb,,,; . I agree that, as the party legally and llnancially responsible for this proposed construction activity, I will abide by all le laws and requirements that govem Owner-Builders as well as employers. . JilZ. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have' 6rovided on thrs 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 with any financial loss you may sustain as a result of a com plaint. Youronly 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 flrm is injured while working on your property, you may be held iiable for damages. lfyou obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verirying 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 retumed to the agency responsible for issuing the permil. ,Vole: A coov of the propertv owner's driver's license, torm notarization, or other able to the nc to be sionature.7') )lt ?B l7Signature of Property Owner (.//^-Date Print name of Owner lrnolrE A\\"V1 AUTHORIZATION OF AGENT TO AC 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 out the above information and certif,/ its accuracy. Property Owner's Signature Date 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 permil rs issued to verify the propefty owner's signature. PL nk.\'\'P51 C,-,u.:,rrAci'\'ily Ass!.n-l,r)'B:s l.l:,i c! io Pra i,c:l',/ Fr.Ilr SANTA ANA CITY COUNCIL m.ulido6santa-ana oro vrcenle Sam enlo Earp,enlolAsanta ana oro solono@santa-sna oo P. Oaed Bâ‚¬.audes dbenavrdes@sanla a.a.oro /rreoas6 sa.la a_. o o sl laF'oAsa'ra.raa o ( i*chele Mad'nâ‚¬z l&yo. Pro Tem, Ward 2 m'marl ne26sanla ana o.o