10196712 - Permit (2) - Laserfiche WebLink

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,,. l:l- I U. t underEtand I may obtatn more information rega.ding my obligalions as an "employer" from the lnternal Revenue Service, the ' Urxted Stares Small Busine;s Admrnist ation, the CaliJomia D;partment of Beneit Payments, and the Calitornia Division of lfldustrial Accic,ents. I also understand I may contact the Cali{ornia Conlraclors' Slate License Board (CSLB) at 1-800-321-CSLB (2752) or 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 financially 1-2-ri responsible for orooosed construction ia rltqta A"c activity at the followjng add 11. I sgrec that, as lho party logally and linancially responsrble for this proposed constructlon activity, I will abide by all ap le law6 and requirements that govem Owner'Bullde.s as well as employers 2- I agree to notify the issuer of this torm immediately ol any additions, deletions, or changes to any ofthe information I have provided on lhis form. Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, the Coniractors' State Licenie Board may be unable lo assist you wilh any financial loss you rnay sustain as a result of a complaint. your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed Contraclc.or emplo-yee ofthat individual or firm is injured while working on your property, you may be held liable fo. damag es. lfyou obtain a permit as O,vnerBuilder and wish to hi.e Contactors, you will be responsible for verifying whelher or not those Contractors are properly licensed and the status of their workers' compensalion insurance coverage. Before a building permit ca. be issued, this form must be completed and slgned by the property owner and returned to the agency responsible for issuing the permil. Nole: A copv of the prcpeftv owhels d vel's license. form notarization. or other v;rification acceptabte to lhe adencv is reduired to be presented when the pormit is issued lo veifu the DroDeftv owner's siqnalute. Signature ol Property Prinl name of Owner AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNE R'S BEHALF Excluding the Notice to P.operty 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 app,y for, sign, and file the documents necessary to obtain an Owner-Builder Permat for m Owner Date:5Jtt/tf, project. Scope of Construction Project (or Description otWork)Q+vn,,rlzl lz.lfchca otri &qlhrz",,--. v 7Z"-tZ tl),Mrn(a r/l s{< S+e , Ja-r'(. fu\a- cA qz7) Project Location or Address Sleve--,n Pha,nn Address of Authorized Agent:_ Phone Number of Authorized Agent qq q - 4l L- qLlo ')- I declare under penalty of perjury that I am the properly owner for the address lasted above and I personally filled out the above information and certify its accuracy t-/tt /t?Propedy Owner's Signature Date i,A^+'(ar\\ l};\1Print Name of Owner: Note: A copy of the owier's drivet's licehse, form notarization, ot other verification acceptable to the agency is required to be presentad when the perrnit is issued to verify tho ptopotty owner's signatore. P:ink:Vf P51 lCo!.rniei'ActiiilyrAssemblyBliislNotice to Prcpcny' Fonn SANTA ANA CITY COUNCIL :!r!]l!9r0!3!l!:!!4l9 LGyd Pt Ten, W6rd 2 Er43i.e!e$::19i&.O9 $g!4!!&@Ea:!r.a!!,!!c lrslclljliadn:rnrrrc db.n!..Eâ‚¬!@93!lg-!4a49 4!l3-a!!â‚¬l4r.!,- lraeâ‚¬ t for more inlormatron about licensed contractors. Name of Authorized Agent: