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-kj* I understand I may obtain more information regarding my'obligations as an "employe/'from the lnternal Revenue Ser- <br />Wce, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- <br />sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800- <br />321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />W I am aware of and consent to an Owner-Builder building permit <br />/arty legally and financiaily responsible for proposed construction activity <br />or"is' - i t t-J \r.J' St-,.."evare4^t1,1 S+ Sa.nl a( <br />applied for in my name, and understand that <br />at the followino ad- <br />Awtx . CA q'2:10 G <br />I am the <br />Signature of Property Owner <br />Print name of owner 5 O <br />-ry\ I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />{fplicable laws and requirements that govern Owner-Builders as well as employers. <br />4Z*l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />fbve provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a <br />license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civilcourt. lt is also important for you to understand <br />that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held <br />liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and returned <br />to the agency responsible for issuing the permit. Note: A copv of the propertv owner's driver's license. form notariza- <br />tion. or other verification acceptable to the aoencv is reouired to be presented when the permit is issued to verifv the <br />propeftv owner's siqnatu re. <br />Ar'.-------'Date: lo''+ - ZPLq7Se? . ce\sil\c,.s <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personalresponsibility, lhereby authorize <br />the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder <br />Permit for my project. <br />Scope of Construction Project (or Description of Work)tMinclo tN Cha"nqL <br />Project Location or Address:Irt-l W Se ue n*e <-r*h st Sanla Ay-,- c*%10L <br />Name of Authorized Agent:bc^b ri e \ct e, . Linv,tne ; <br />lo b 3 F- fto l,.f A1,€,Orv\O tN CA <br />nt <br />Address of Authorized Age <br />Phone Number of Authorized Agent.131-.) 424 -\bz1 <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date lo q. 2-o <br />Print Name of owner: 5O se F . Ccr.si \\r,tS <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- <br />quired fo be presented when the permit is issued to verify the propefi owner's signature.