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,/' S5 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any finbhcial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the worknranship or materials. \y', ]rOerstanO I may obtain more information regarding my obligations as an "employe/'from the lnternal Revenue Slrvice, the United States Small Business Administration, the California Department of Benefit Payments, and the Califor[ia Division of lndustrialAccidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. ,n ..- \A/f O I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I ::il:: j".y resar ry, "Vf J"'" uf.rffiIr;fir 0ryseo )?fl['"'\!'tl',] 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by al applica ble laws and requirements that govern Owner-Builders as well as employers. 2. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the rmation I have proved 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 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 individual or firm is injured 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 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 responsible for issuing the permit. Note: A copv of the propertv owner's driver's license. form notarization. or other verification acceptable to the aaencv is reouired to be presented when the permit is Signature of Property Owner Oq-L)-D t 6 Print name of owner {-t €v (.,l./fra^l ac c o J hr'A/ / oc-(tA 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 a Project Location or Address 70/ //./t/bill t7' Name of Authorized Agent:Dr r, / ,(.os ) ouz Address of Authorized Phone Number of Authorized Agent:7 I declare under penalty of perjury that I the property owner for the address listed above and I personally filled out the above information and certify its accuracy Propefi Owner's Signature:0 'Lt-D Print Name of Owner:1<)< . a.o otfu! furd aeo{,t + 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 ls lssued to verify the property owner's signature. Bnegrete:WP51/Counter Activity/Assembly Bills/Notice to Property Owner & Authorization Form 1i2010 es.nt t0 / l/. /4,4)"J <T <r1^n4 4/,/A .4- g)7D t