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\_,0 <br />le0ally an <br />address: <br />I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />d financ ly responsible for proRo sed construction a at the followi ng <br />Z o <br />-LlappICa <br />1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />ble Iaws and requirements that govem Owner-Builders as well as employers. <br />X 12. t agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />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 license, <br />the Contractors' State License Board may be unable to assist you with any Ilnancial loss you may sustain as a result of a com plaint. <br />Youronly remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed <br />Contractor or employee of that individual or flrm is injured while working on your property, you may be held liable for damag es. lf you <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are <br />properly Iicensed 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 to the <br />agency responsible for issuing the pe te: A copy of the property owner's driver's license, LofrlD notarization. or other <br />Yerification able to the ,s <br />siqnature.r/r-^/ur-Signature of Property Owner Date /7 <br />PERTY NER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the <br />following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my <br />pmject. <br />Scope of Construction Project (or Description of Work) <br />Project Location or Address <br />Name of Authorized Agent <br />Address of Authorized Agent <br />Phone Number of Authorized Agent <br />I declare under penalty of pe4ury that I am the property owner for the address listed above and I personally frlled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner: <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to <br />be presented when the permit is issued to verify the property owner's signature. <br />PL ink:'!'V P51 i CounterAct vllylAssernblyB illsr Nolice to Properly Form <br />SANTA ANA CITY COUNC]L <br />moulrdo@sanla-ana oro <br />M3yor fto Tem. Wad 2 <br />mrmarline.@sanla-ana oro <br />Vicenle Sarmienb <br />vsam e.lo6sanla-ana.oro isgLqls@$-d4slElrg dbenavidesrosanla-anaoro v eoasrosanla'anaoro slr.aero@sanla-araoro <br />\]-g. f understand lmay obtain more information regarding my obligation's as an "employer" from the lnternal Revenue Service, the <br />lyn'iied States Small Business Administration, the California Department of Beneflt Payments, and the Califomia Division of lndustrial <br />Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at '1-800-321-CSLB (2752) or <br />www.cslb.ca.oov for more information about licensed contractors. <br />Print name of Owner I