10194881 - Permit (2) - Laserfiche WebLink

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J_.L g. t understand I may oblain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of BenDflt Paynrents, and the Calilornia Division of lndustrial Accidents. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at 1-800-32'1-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. lâ‚¬, O. , 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 responsible for proposed construction activity at the followingaddress: 7.QO6 w. lSnogk e -J-' J ., 1 1 . 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 govern Owner-Builders as well as employers. JLl2.lagreetonotifytheissuerofthisformimmediatelyofanyadditions,deletions,orchangestoanyoftheinformationlhave provided on this form. Licensed contractors are regulated by laws designed to protect the public. lfyou contract with someonewhodoes 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. Youronly remedy against unlicensed Contractors may be in civil court. ltisalso important for you to understand thatif an unlicensed Contractor or employee ofthat individual orfirm is injured while working on your property, you maybe 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 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 responsibfe for issuing the permit. Nole: A copv of the propeftv owner's driver's license, form notarization. or other verification acceptable to the aqency is recuired to be presented when the permit is issued to verify the propeftv owner's sianature. Signature of Property Owner \')Date il-2-l-'Lat7 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 Location or Address Name of Authorized Agent I declare under penalty of perjury that I am the property owner for the address listed above and I personally lllled 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. PL in k:\i, P5l iCcunterAclivilylAssemblyB iils:l'lctice ic Prcseily Fcrm SANTA ANA CITY COUNCIL moul do6sa.ta 'ana oro Mayor Pro Tem, Ward 2 mi6an nez@santa ana.oro Mcenle Samieno vsarmrenbras6nla ana.oro 6olorio@santa-ana.oro P. Oav d Benavides dbenaudes@sanla-ana oro vrlleoaslasanla'ana oro sl naero@sanla-ana oro Print name of Owne, \Ose Zxf-rtl,rEZ ScopeofConStruCtionProjeCt(orDeScriptionofWork):- Address of Authorized Agent: Phone Number of Authorized Agent: _