10196491 - Permit (2) - Laserfiche WebLink

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h ff-NS. f understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the Califomia Department of Benefit Payments, and the Califomia Division of lndustrial Accidents. lalso understand lmay contact the California Contractors' State License Board (CSLB) at 'l -800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. A [ ,0. tam aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally a address nd fi nct res construction activity at the following X D f ',. f agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all epplicable laws and requirements that govem Owner-Builders as well as employers. [\t Z. t ugr"" ,o 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 llnancial loss you may sustain as a result of a com plaint. Youronly remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an u nlicensed Contractor or employee ofthat individual or firm is injured while working on your property, you maybeheld 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 ovyner and returned to the agency responsible for issuing the permit. Nore;A coDv of the Drooertv owner's license, form notarization, or other ,s to be ted when the ,s ,s sionature. Signature of Property Pdnt name of Owner Owner Date e 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 Scope of Construction Project (or Description of Work): Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Property Owner's Signature Date 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 signaturc. PL ink:Vr' P51 lCou nlerActl\,l1y.rAssem blyB ilis,'Notice io Property Form SANTA ANA CITY COUNCIL mo!ildo@sanla-ana.oro Mayor Pro Tem, Ward 2 m hanrnez@sa.ta ana oro Vicente Samienlo Earmienlo@sanle-ana.oro isoronorosanla-zna.oro P. David Benavdes dbenav des@'sa.ta-ana oro Project Location or Address: Name of Authorized Agent: Phone Number of Authorized Agent, Print Name of Owner: Jlan Mllegas SalTinaierc Ward 5 Wa.d 6 ivilleoas@sanla-anaoro stinalerolasanra-ana.oro