10195018 - Permit (2) - Laserfiche WebLink

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t'.4 L 9. I undersland 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 lhe California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.qov for more information about Iicensed contractors. \4 L I 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 leoallv and financiallv resoonsible for orooosed construction activitv at the followino aoioreis: l o r rJ, F,o. \n_ p.rioo \( L { saF},T,1 a. r,.t A c,{ .l LJ <_, t h,4 t' ' ' *- 11. 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. tr/r:_:12. I agree to notity 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 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 als o important for you to understand that if an unlicensed Contractor or employee of that individual or llrm 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 propedy licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this agency responsible for issuing the permit. must be completed and signed by the property owner and returned to the A copy of the propertv owner's driver's license, form ootarization, or other verification acc to the ,s be nted when the rmit is issued to ve the owner's s iq nature. Signature of Property Owner printnameof owne, | 1 lciu â‚¬ol)ez 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 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 POect (or Description of work) Dare: lz /o-t /2_o l-\ I o I 6 1:/-r11rPJ t.)-oo lz- L x\ SAxl TA z-rr.-l A,cA IZIOOProject Location or Address Address of Authorized Agent: Phone Number of Authorized Aqent: I declare under penalty of perlury that I am the property owner for the address listed above and I personally filled out the above information and certify 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 permit is issued to verify the property owner's signature. _. . :, l- ' i - ,' :' i SANTA ANA CITY COUNCIL mp!lrdo@sanla-ana o.o ilsys Prc Tem W6rd 2 hrroninez@santa ana oro V'cenle Samiento Eamrenlo@sanl, 3n. oro lreb!p@r@E:e!!.p!g P Davd Benavdes dbenEvdes@sanG ana.o.o u-Le!!!@rdr.34e,p!9 strnarm@3anla ana oro Name of Authorized Agent: