101102760 - Permit (4) - Laserfiche WebLink

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-1=t_9 I understand I may obtain more information regarding my 6blagations as an "employed from the lnternal Revenue Ser- vic6, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. lalso understand I may contact the California Contractors' State License Board (CSLB) at1-800- 321-CSLB (2752) or www.cslb.ca.oov for more information about Iicensed contractors. =_->L10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party dress lr nd finan responsible for pro sed con structio activity at the fol lowi ng ad-) 7az-r,ui CL 5{-,t t. I agree that, as the party legally and flnancially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 'lS--t Z I 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 unable to assist you with any flnancial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civi! court. lt is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible fo[ 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. ivote; A copv of the prooertv owner's driver's license. form notariza- tion. or other verification acceptable to the aaencv is reouired:Lo b9 pfqsented when the permit is issued fo verifv the propeftv owner's sidnatu re. Signature of Property Owner --,,.--\ , /t/ :, ;r,Date Print name of Owner AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the executaon 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 documents necessary to obtain an Owner-Builder Permit for my prolect. Scope of Construction Project (or Description of Work)B e lc+ce- 3L,"bs R ((fr(,,, Project Location or Address gI,3 w Name of Authorized Agent : U LJL ? z-70u=-J I-->ct ^ \,,.-/ ct (! Address of Authorized Agent:L.\ 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 fllled out the above information and certify its accuracy , l,l *r,,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 re- quired to be presented when the permit is issued to verify the property owner's signature. a I ,a .1 Property Ownels Signature: