Laserfiche WebLink
,Fn-c <br />2tfl ,understand I may obtain more information regarding my obligations as an "employed'from the lnternal Revenue Ser- <br />vice, the United States Small Business Administration, the California Department of Beneflt Payments, and the California Divi- <br />sion of lndustrial Accidents. lalso understand lmaycontactthe 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 />.dt e' <br />|thO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />party I <br />d ress: <br />,4+ <br />egally and flnanc on le for NS activity <br />3 <br />ng 4)L <br />Zu---11.1 agree that, as the party legally and financially responsible for this proposed construction activity, lwill abide by all <br />apIticable laws and requirements that govern Owner-Builders as well as employers. <br />,Gs s_ <br />Q_qhZ I 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 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, 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. A/ote;A coov of the DroDertv owner's driver's license.fo rm n ota nza- <br />ac able to the enc when the ermit is issued to <br />proDertv owner's siqnature. <br />l-f-7oSignature of Prope(y Owner <br />Print name of owner L t @L g2o? o9{ <br />qa,,o L. ilt*r-Lo ab b r 7 <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 />Scope of Construction Project (or Description of Work) <br />Project Location or Address Aq3q J. E€owtt"L*?- <br />Name of Authorized Agent <br />Address of Authorized Agent:)37q S B.oao(r, <br />Phone Number of Authorized Agent:-ttL/_ tqo_t71 ( <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 7-T-to <br />p1nt Nameof own"r. 6cc hb-tlt <br />Note: A copy of the owner's driver's license, form notarization, or o ther ve fication acceptable to the agency is re- <br />quired to be presented when the permit is issued to verw the propertyr owner's signature. <br />Ka*Lke^ /J, . lr,lu L <br />q