10189377 - Permit - Laserfiche WebLink

Home Browse Search

..:r.:{_8. I under stand as an Owner-Buil der if I sell the pro perty for"Wh iel ,~his perm it is issued, I may be held liable for any fi nancial or persona l injuries susta in ed by any subsequent owner( s) tha t result from any lat ent construction defects in the workmansh ip or mater ials. T\J 9. I u nderstand I may obtain more information re garding my obli gations as an "employer" fro m the Internal Revenue Service , t he United Sta tes Sma ll Bu s iness Adm inistrat ion, the Ca lifornia Department of Benefit Payments, and t he Cal iforn ia D ivision of Ind us trial Accide nts. I also u nderstand I may contact the Ca lifornia Contractors' State License Board (CSLB) at 1-800-32 1-CSLB (2752) or www.cslb.ca .gov for more information about licensed contracto rs. -(\I 10. I am aware of and consent to an Owner-Builder build ing permit appl ied for in my name, and understand that I am the party legally and financially respo nsible for proposed construction activity at t he following a ddress: 11'1 rPlc..:F\Joy L~ I s~ 14:rJ+ T-7--70,6 ~ 11. I ag r ee that, as the party lega ll y and financially responsible for th is proposed construct ion activity, I will abide by all ap pl icable laws an d requirements that gove rn Owner-Bui ld e rs as well as employe rs. T'112. I ag r ee to notify the issuer of t his form immediately of any additio ns, del etions , or changes to any of the i nformation I have provided on this form. L icensed contractors are r egu lated by laws designed to pr otect the public. If you contract with someone who does not have a license, the Co ntractors' State Li cense Board m ay be unable to ass ist you with any financia l loss you may sustai n as a result of a complaint. You r only remedy against un licensed Con t ractors may be in c ivi l court . It is also important for you to understand that if an un lice nsed Contractor or e mployee of that ind ivid ual or firm is injured whi le working on your property, you may be h eld lia ble for damages. If you o bta in a permit as Owne r-Builder and wish to hire Contactors, you wil l be respons ible for verifying whe t her or not those Contract ors are properly licensed and the status of the ir worke rs' compensation insura nce coverage. Before a building permi t can be issued, this form must be completed and signed by the property owner and ret urned to the age ncy responsible for issuing the permit. Note: A copy of the property o wner's drive r's license, fo rm notarization, or other verification acceptable to the agency is required to be presented w hen the permit is issued to veri the ro ert owner' i nature. Pri nt name of Owner ----'~_......"+-'-,,_lf-XF--V~v-....'---"---------------- AU THORIZAT ION O F A G E NT TO ACT O N PRO PE RTY OWN E R'S BEHALF Excluding the Notice to Property Owner, the execut ion of which I understand is my personal responsib ility , I hereby authorize the following pe r son(s) to act as my agent(s ) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Perm it fo r my project. Scope of Construction Project (or Description of Work):. _______________________ _ Project Location or Address:--------------------------------- Name of Authorized Agent:---------------------------------- Add ress of Authorized Age nt: ________________________________ _ Phone Number of Authorized Age nt ______________________________ _ I declare under penal ty of perjury that I am the property owner for the address listed above and I personally fil led out the above i nformation and certify its accu racy. Property Owner's Signature: ______________________ Date: _________ _ Print Name of Owner: __________________________ _ N o te: A copy of th e owner 's drive r's ficens e, form notar ization, or other ve rifica tio n acceptable to th e age n cy is required to be presente d when the p ermit is issued to verify th e prope rty own er 's signature . Miguel A. Pulido Mayor MPuhdo@santa-ana.org SANTA ANA C ITY C O UNCI L Vmcent F Sam11en to M1che!e Marune;: Angehca Amezcua P. David Benavides Mayor Pro Tern. Ward 1 Ward 2 VSarm1ento@san1a-ana.org MM ar11nez@san ta-an a .org Ward 3 Ward 4 AAmezcua@santa-ana.org DBenav1des@santa-ana.org Roman Reyna Wards RReyna@sanla-ana.org Sal TinaJero Waro6 STina1ero@santa-ana.org