101104950 - Permit (2) - Laserfiche WebLink

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N/ t ' understand I mal obtain more jnformation regarding my obligations as an'employer" from the lnternal Revenue Ser- iice, the United States Srnall Business Administration, the California Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. I also understand I may conlact the California Contractors State License Board (CSLB) at 1-800- 321-CSLB (2752) or vv,v,,v.cslb ca qcv for more information about licensed contractors. \)y fO I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that t am the patly dre ss legally and Fin a nc ia ll yt sp ibt lor ropos co slruct n actrvity the N/11. I agree that, as the party legally and financially responsible For this proposed construction activity, I will abide by all applicable laws and requlrements that govern OwnerBuilders as well as employers. n A, tagree to notify the issuer of this form immediately of any additions, deletions or changes to any of the information I have provaded 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 Contractcrs State License Board may be unable to assist you with any financral loss you may sustarn as a result of a complaint. Your only remedy against unlcensed Contractors may be in civil court. lt is also important for you to understand that if an unlrcensed Contractor or employee of that individual or firm is inlured 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 verifyrng 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. Note: A copv of the propen tion. or other verification acceptable to the aoencv is required to be presented when the permit is issued to verifv the propertv owner's sienature Srg nature of Property Owner Date io llul2sy2 Prjnt name of owner 1t1r, *r l;fVrC\i 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 flle the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Descrjption of Work) Prol ectlocationorAddress; tl)cl il \kU fu,, 1t^-+z h"{)(,} qlloLl Name of Authorized Agent Aacrrr\, ?. t"rwt"n Address of Authorized Agent 5LJ o I 1)lc Phone Number of Authorized Agent 1tLl. )L<-85 <> 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. Property Owneas Signature n,n*o/,4,o"r" o ltqltn,) print Name ot owner: Il0/Mr1 l-, utA l, Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- quired to be prcsented when the permit is issued to verify the property owner's signature. ,f /1