10197080 - Permit (2) - Laserfiche WebLink

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licensed subcontractors and the number of structures does not exceed four within any calendar years, or all of the work is performed under contract with a licensed general building Contractor. -Utr. t understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that resull from any latent construction defects in the workmanship or materials. ,, '9. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about ticensed contractors. \/ 10.1 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 finar-rcially responsible for pro address: 7;3a S. bL-<l.r AN, DA. posed construction activity-at the following Sr\ Nl r\ ,\ Cr.tA I2)a)s --r/ll I agree that, as the pa(y legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. t,/ lZ. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the informalion 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 complaint. Your only remedy against unlicensed Contractors may be in civil court. lt js 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 for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Signature of Property Owne Date: * lzoltL Print name of owner PA U L \f A fJ AUTHORIZATION OF AGENT TO ACT ON PROPERry 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 lile the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Project Location or Address Address of Authorized Agent I declare under penalty of perjury that I am the property owner for the address listed above and I personally frlled 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 properly owner's signature, SANTA ANA CITY COUNCIL moulido@sanla-a.a.o.o Vlcente Sa.mienlo vsamiento(asa.la-ana.oro lcqlprig@s3lE:a!3lrs dbe.avLdes@santa-araoro v eoas@sa.la-snaoro sl naiero@sa.la-a.a ora 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. /Vofe; A coDv of the proDertv owner's driver's license, form notarization, or other verification acceptable to the aoencv is reouircd to be presented when the permit is issued to verifu the Dropeftv owner's siqnature. Name of Authorized Agent: _ Phone Number of Authorized Agent: _ Mayor Pro Tem. Ward ? m marlr.ez@santa-a.a oro