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10196491 - Permit
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10196491 - Permit
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Last modified
6/2/2021 9:42:54 AM
Creation date
6/2/2021 9:42:53 AM
Metadata
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Template:
Permit
Permit Number
10196491
Full Address
2017 S Forest Ave
Permit ID
241724
Master ID Number
2018-143447
Project Name
De Los Angeles Residential Reroof
Street Number
002017
Street Direction
S
Street Name
Forest
Street Suffix
Ave
Building Use Code
Resid-1 unit
Job Types
Reroof
Permit Type
Building
Applied Date
5/21/2018
Issued Date
5/21/2018
Finalized Date
5/30/2018
Flood Zone
X-0602320257J
Description of Work
Reroof w/t.o.-Remove and apply comp shingles/sheathing to remain/handout given
Nature of Work
Reroof
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h <br />ff-NS. f understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the <br />United States Small Business Administration, the Califomia Department of Benefit Payments, and the Califomia Division of lndustrial <br />Accidents. lalso understand lmay contact the California Contractors' State License Board (CSLB) at 'l -800-321-CSLB (2752) or <br />www.cslb.ca.oov for more information about licensed contractors. <br />A [ ,0. tam aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />legally a <br />address <br />nd fi nct res construction activity at the following <br />X D f ',. f agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />epplicable laws and requirements that govem Owner-Builders as well as employers. <br />[\t Z. t ugr"" ,o 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 llnancial 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 u nlicensed <br />Contractor or employee ofthat individual or firm is injured while working on your property, you maybeheld 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 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 ovyner and returned to the <br />agency responsible for issuing the permit. Nore;A coDv of the Drooertv owner's license, form notarization, or other <br />,s to be ted when the ,s ,s <br />sionature. <br />Signature of Property <br />Pdnt name of Owner <br />Owner Date <br />e <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 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 />project <br />Scope of Construction Project (or Description of Work): <br />Address of Authorized Agent: <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 Date <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 signaturc. <br />PL ink:Vr' P51 lCou nlerActl\,l1y.rAssem blyB ilis,'Notice io Property Form <br />SANTA ANA CITY COUNCIL <br />mo!ildo@sanla-ana.oro <br />Mayor Pro Tem, Ward 2 <br />m hanrnez@sa.ta ana oro <br />Vicente Samienlo <br />Earmienlo@sanle-ana.oro isoronorosanla-zna.oro <br />P. David Benavdes <br />dbenav des@'sa.ta-ana oro <br />Project Location or Address: <br />Name of Authorized Agent: <br />Phone Number of Authorized Agent, <br />Print Name of Owner: <br />Jlan Mllegas SalTinaierc <br />Ward 5 Wa.d 6 <br />ivilleoas@sanla-anaoro stinalerolasanra-ana.oro
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