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Hay 7l &18 01:36F1'l lF Fax 949475-7010 page 3 <br />f.i undcGtand I may obtain more inforrralion regarding m y obligaliong es En 'emptoyer'{rom lhe lnlemal Revenue Servics. .lhe <br />iEd Stabs Smsl Busrness Adminis!'ation . the Calibmis Depa nmsnt of 36nclit Paymenls, and lhe Call.-omia Oivisron ol tndustrialActidenB. I also und€rEland I may c6nteet th6 C.l;{orni: Conlracto.3. Slclr Lice nse goard (CSLB) 6t 1.8OO.32t.CSLB (2752) orv',urvl.crl6. canot for mOfO i <br />V .o. t ". *," of un <br />nb(mauon about lc€nsed contracto,r. <br />d con66nt to an OvrnehBurtder build ilrg ponnit appled lor in my nam€. snd lnd€r61snd thal t arn the partteg8Uy 6nd finaociolly €spo.rsrblo for Oropo6od construcdon a ctivity at lne loltowlng <br />.agrs€ that aE thB pal. bgslly snd fin.nciaiy .€sponsiblc lor th iE propoGed constr,rction actvity, I wi aDide by altlaw6 Itld faquagmef(s that gov.m oN €r€urlderr aa u/gll s8 emptofgr3. <br />12. I agrBe lo notfy the issuor of thi6 lorm lrn mgdiatoly ol any addiions, delotlons, or changes lo any ol the intoflnstron I hsvaptovid€O on thB n ffil <br />1I <br />IT:td_cg"q*T aG regurEtcd by taws desrgnod io Dotect thO pubtc. lf yqv contract wilh somsone wfio doos not havE a licens6,l'le uoorrecldr6- Stato !-rcsn6t Board moy.bo unoble to assist you w(h any 6nanc al loss you may suslarn as a te8utt O, a ({mptaiol <br />Your Only rg6g6y 5g3ifl$ unticensed ConttActors may bo in cl;itqou.t. ltk steo 6pona,rt tor yo\.1 to unders,tend tha f a^ lnticanaec,co.nracr oi cmplojee ol thsl lndivioual or firrrl is rniured while t!6ft'ng on your prao€ny, you may be nold tiabte loi ilamages. ft [uoboAin a Parmit As OrnBr-Builder and \ltish to hrrB Conl8ctors. you wtr -De reiponsible foi venlyingviretfrer oi noi tt,oso Confoctors arrprooert licona€d Bnd the stalus ofthelt work€rs' compensatjon nsurance covc,age <br />&brr a building p.rmt( can b. l$uorr, this form <br />sg.ncy rllilonEtbt6 fof lslulng tho permit Notel <br />Oa <br />git rrdrut, <br />Sigrlatr,rrB of PropErty <br />Pdnt namo ot Orrisr ril <br />Name of Authoriu ed Agen! <br />AddrBso ot Aufio/tzed Agent: <br />&atlo,rey Atle&D <br />AUTHO'IIzAIICIN OF AGENT TO ACT Orl PROPERTY OWHER'S AEHALF <br />PPSS^!:Ytr. to Plope(y Ou,ner, ths €x*u,rion or wiich I undacbM is fly petsorat responribitily, I hereby aulmrizo theIula{lng pe6on(s) to ect aE my a9€n(5) to appv for, glgn. and ltte the documenb neceseary to obrain an orvdenbuiuer permit iy rnyprcpct <br />ScoP€ 0t Conslrlaion P?olect {or DescJipion oI Wor e €-c+n c"Q- <br />Proi€El Loceton or Address:n aVE o7 <br />murl bt camDletsd lnd rlgn.d bylhe prepony own.r and rutum€d to lh. <br />o. othqtA cdDv lhe orD6e,rw div*s licenEc- larm fiote <br />Date 1->t'ttr <br />gerjury thal th€erv owoor fgr tia addr€Ss list€d aggve e ersonelly lill€d out lhe gDove <br />5->\-\Y <br />Tr\C- <br />30\ e..,. Nu<-AhA 1glot <br />Phone Nurnb€r of Ar]thonzed Agent g{q -(rL _rooo <br />I d€dsre undar penelty gt <br />inbrmafion and can y [s <br />Pr"porty Own6/s Signatu <br />Print NBmc gt OwneE <br />SCCuracy <br />re. <br />{ <br />Nota: Acop, olUlo ovrna(a license, ,om note,lzlli on, o?othet vstificrban cccoptible lo lhe agdttcy is ,equir6d tob 9tsl6,urm,d when lho pcnnit i,isEued lo varlfy aho pr!ggtty owoe/E ,lgtrrluro. <br />PUhkWPS 1 rCounlerAcdvityiA Ssem0l,€ills/Notrce lo P(Opgrty Fgmi <br />SANNA ANA OTY COUNCIL <br />4g!1ii$or!!:tDr,!lr l.lqlos.glllaJlo <br />.dlp <br />Dare: <br />iL\or P.o-I.G Wrd I <br />otrlllllaEaaLaaai9 6.i.vh.rlo.E,Mr. 16 !i{6arlau r E-r1, .7.rtla.h..&!86{nr c. <br />ao'd 90:SI 8I0a IZ 6eh <br />Erlr..osE.a66 <br />0618-tsS-6t6:rej luaLLla6eue4 JalPsunH