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20170572 - Permit
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20170572 - Permit
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Last modified
6/2/2021 7:51:36 AM
Creation date
6/2/2021 7:51:33 AM
Metadata
Fields
Template:
Permit
Permit Number
20170572
Full Address
515 1/2 W Cubbon St
Permit ID
262202
Master ID Number
2020-157026
Project Name
Miscellaneous Counter1 Permit
Street Number
000515
Partial
1/2
Street Direction
W
Street Name
Cubbon
Street Suffix
St
Building Use Code
Resid-2 units
Job Types
Miscellaneous
Permit Type
Electrical
Applied Date
1/13/2020
Issued Date
1/13/2020
Finalized Date
1/27/2020
Flood Zone
X-0602320276J
Description of Work
Hand out given. Auth on file.
Nature of Work
Service Meter
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a 9. I understand I may obtain more information regarding my otlligations as an "employea'from the lnternal Revenue Ser- <br />0. I am aware of and consent to an Ow ner-Builder building permit applied for in my name, and understand that I am the <br />posed construction activity at the following ad-gall T 2- <br />nciall nst le for <br />.,!ice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- <br />sion of lndustrial Accidents. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at1-800- <br />321-CSLB (2752)or www.cslb.ca.qov for more information about licensed contractors <br />_1 <br />party le v po <br />d <br />','1'1.Iagreethat,asthepartylegallyandfinanciallyresponsibleforthisproposedconstructionactivity, lwill abidebyall <br />ay'pf,cable laws and requirements that govern Owner-Builders as well as employers. <br />I ,^Jn. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />tf5ve 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 flnancial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civil court. 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, youwill 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 4?)t( A-z-\Date:| - )V- 7at-c\ - ={Z-*tsy-,a-rz t:4<-4>A-4Print name of Owner <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 />Name of Authorized Agent <br />Address of Authorized Agent: <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally fllled out the above <br />information and certify its accuracy. <br />Property Owneds Signature Date <br />Note: A copy of the owner's driver's ,icense, form notarization, or other verification acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the property 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. /Vote.' A copv of the propertv owner's driver's license. form notariza- <br />tion, or other veification acceptable to the aoencv is reouired to be presented when the Dermit is issued to verifv the <br />DroDertv own er's si d n atu re. <br />ScopeofConstructionProject(orDeScriptionofWork): <br />Phone Number of Authorized Agent: <br />Print Name of Owner:
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