10296483 - Permit - Laserfiche WebLink

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f-i.,^- 9. Iunderstand Imayobtainmore information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of Beneflt Payments, and the Califomia Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-32'l-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. ' -T-L 10.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally an address: d financiall v responsibl e for proposed constructi o n activity at the foll ng --z-a__'|1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. --4712.1 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 ,lnancial loss you may sustain as a result of a com plaint. Youronly remedy against unlicensed Contractors maybe in civil court. lt is also important for you to understand thatif an unlicensed Contractor or employee ofthat individual or firm is injured while working on your property, you maybe held liable for damag es. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verirying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Arore.' A copv of the proDeftv owner's driver's license. form notarization. ot other verification acceptable to lhe v is reauired to be Dresented when the Dermit is issued to ye rifv the Drooeftv owner's sianature.ISignature of Property Owner \i*Z o.t , oE /r,t /t B Print name of Owner AUTHORIZATION OF AGENT TO ACT ON PROPERTY OW NER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the fol!owing person(s) to act as my agent(s) to apply for, sign, and file the documents necessary lo obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) o Name of Authorized Agent I declare under penalty of perjury that I am the property owner for the address listed above and I personally fllled out the above information and certify its accuracy. Property Owner's Signature Date Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued lo verify the propefty owner's signature. PLin k:\^j P5l icounlerActivltylAssem blyB illsi Notice to Properly Fcrm SANTA ANA CITY COUNCIL mouLdolosant6 ana.oro Mayor Pro Tem, Ward 2 m'martinez@sanla-ana.o.o vsa.mrenlo6sa.la'ana o.o isal.a!!@s4E3!3.9!q P. David Be.avides dbenavldes@sa.ta-a.a.oro !r!.ca!s,@E!E=E-E!. slrnare,olasanG-a.aoro 1 Project Location or Address: Address of Authorized Agent: Phone Number of Authorized Agent: Print Name of Owner: