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\\r)j-.LF' l understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the <br />United States Small Business Administration, the Califomia Department of Benefit Payments, and the Califomia Division of Industrial <br />Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or <br />www.cslb.ca.oov for more information about licensed contractors. <br />I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />nancially responsible for proposed construction activity at the following <br />address <br />( ik[. t aqree tnat, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />A;ffibE lais and requirements'thai govem Owner-Builders as well as employers. <br />!=$q. t agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, <br />the Contractors' State License Board may be unable to assist you with any flnancial loss you may sustain as a result of a com plaint. <br />Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed <br />Contractor or employee of that individual or lirm is injured while working on your property, you maybe held liable for damages. lfyou <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are <br />properly licensed and the status of their workers' compensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the <br />agencyresponsibleforissuingthepeImit.Note: <br />verification acceptable to the agency is required to be presented when the permit is issued to veify the p@pedy owner's <br />sionature. <br />Signature of Property Date: )e <br />Print name of Own <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the <br />following person(s) to act as my agent(s) to apply for, sign, and flle the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description of Work) <br />Project Location or Address <br />\ <br />Address of Authorized Agent <br />Phone Number of Authorized Agent: <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above <br />information and cerlify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner: <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to <br />be presented when the permit is issued to verify the property owner's signature. <br />SANTA ANA CITY COUNCIL <br />moulrdoaasanl3-ana o.o <br />Mayo. Pro Teh. Ward 2 <br />mrhan nez@sanla-ana oro <br />Mce.te Sam'e.to <br />6smrenl0(asanlr-ara oro ls0lono@sanl6-an3.oro <br />P Oav'd B€nardes <br />dbenavrd.s@sanrs-ana o.a rvrlrsds@sa.ta-ana oro sn.arero@sant3-ana oro <br />Name of Authorized Agent: