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Q\L n , understand I may obtain more information regarding my obligations as an "employef'from the lnternal Revenue Ser- <br />vice, the United States Small Busjness Administration, the California Departnent.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 />AM10 I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />tsa'rty reealy and nnanciaily ,QttillE <br />H,"o"gf.|tsjo,%,131,,r " ,&{",,"1t,ryt } <br />(iAIf l. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />Epplicable laws and requirements that govern Owner-Builders as well as employers. <br />(\]t Z. t agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />have 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 againsl unlicensed Contractors may be in civil court. lt rs 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 />Signature of Property Owner .?*-)rD;".-Date <br />Print name of Owner Qu+Ne e-l <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 personal responsibility, I hereby 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 />Project Location or Address <br />v <br />tl <br />Address of Authorized Agent <br />Phone Number of Authorized Agent: <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 certily its accuracy. <br />Property Ownels Signature Date <br />Print Name of Owner <br />Note: A copy of the owner's driver's ,icense, form notarization, ot other verification acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the propefty owner's signature, <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. ,Vofe.' A coov of the propertv owner's driver's license, form notariza- <br />tion, or other verification acceptable to the adencv is required to be presented when the oermit is issued to verifv the <br />propertv owner's sion atu re. <br />2s LO <br />? <br />ScopeofConstructionProject(orDeScriptionofWork): <br />Name of Authorized Agent: