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/ (l* ' understand I may obtain more information regarding my ob'ligations as an "employei'from the lnternal Revenue Ser- vice, the United States Small Business Administration, the Califomia Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. lalso understand lmaycontactthe Califorrria Contractors' State License Board (CSLB) at1-800- 321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. A i \-210. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following ad- dress: 1. I agree that, as the party legally and flnancially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. (\" 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 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 li Y Before a building permit can be issued, this\ to the agency responsible for issuing the pe censed and the status of their workers' compensation insurance coverage. form must be completed and signed by the property owner and returned rmit. ,Vote.' A coDv oLthe ploperty owner's driver's license, form notariza- o d when the rmit is issued to the DroDertv ow ner's siqn atu re. Sig nature of Property Owner Date Z t I6 ?tc Print name of Owner B Lea- AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Scope of Construction Project (or Description of Work)ir s+a.il ,'h Iatt"tl dprhLrr^,t. C (oler r l a,le, tr. -e QT ku< S.+'& 4 A 9^^1" Axq d 270 lo l',on 14 ^ Address of Authorized Agent:O D, Ed;€f ftr.,". 9u-,le* A sa,"+r^ h^cA qL70 Phone Number of Authorized Agent 7t4-) r+>o+t8 I declare under penalty of perjury that I am the property owner r the address listed above and I personally fllled out the above information and certify its accuracy Property Owneis Signature Date 7-[l3 I !_o Print Name of Owner Br.l^".L Lt <, Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- quired to be prcsented when the permit is issued to verffy the propefty owner's signature. Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authodze the following person(s) to act as my agent(s) to apply for, srgn, and file the documents necessary to obtain an Owner-Builder Permit for my proJect. Project Location or Addressl Name of Authorized Agent: