103104991 - Permit (2) - Laserfiche WebLink

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^ Z-n I understand I may obtain more informahon regarding my obligations as an 'employei'from the lnternal Revenue Ser-'"vicb the Unrted States Small Eusiness Administration, the California Department of Beneflt Payments and the California Drvi- .sion of lnduskial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800- 321-CSLB (27 52) or ,Mnu.cslb ca qc't for more information about licensed contractors. ..4r|.l am aware of and consent to an Owner-Builder building permit applred for in my name, and understand that I am the party legall and flna nc U ia ll responsible for pro sed construction activit at the followi ng ad- d ress o -t0 o/ 1 1. I agree that, as the pady legall/ and flnancjally responsible for this proposed constructron activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. ,., ,il,, I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I' have provided on thrs form. Ljcensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license the Contractcrs State Ljcense 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 is also important for you to understand that if an unlicensed Contractor or employee of that indrvidual or firm is inlured while workrng on your property you may be held liable for damages. lf you obtain a permit as OwnerBuilder and wish to hire Contactors, you will be responsible for veriiTing 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 properlv owner's driver's license. form notariza- tion. or other verification acceptable to the agencv is req uired to be oresented when the Dermit is issued to verifv the proDeftv ownet's sionature. Srg nature of Property Owner Date C ,z/o-r- Print name of Owner AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excludrng 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. ot 9/+o\/'lE<otr ,{ld"94ER- Scope of Construction Project (or Description of Work)a Project Location or Address c4 o/ Name of Authorized Agent:Se(r Belrlgr Address of Authorized Agent D'e ?z Phone Number of Authorized Agent ?/7-?zs- N6e 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 Ownel,s Signature Date lv o Print Name of Owner Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is rc- quired to be presented when the permit is issued to verify the propefty owner's signature.