104103093 - Permit (2) - Laserfiche WebLink

Home Browse Search

.fn.g 0:,b ,understand I may obtain more information regarding my obligations as an "employe/ from the lnternal Revenue Ser- vice, the United States Small Business Administration, the Californa Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- 321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors..3t t' 'l'LlO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the legally and fi n anct pon le for activity rng 4J4-e Zu--11.1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all ap6licable laws and requirements that govern Owner-Builders as well as employers. ,4ts_ f<-ghZ I 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 flnancial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civll court. lt is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held Iiable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying 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. A/ofe:A coov of the DroDertv owner's driver's license. form notariza- tion, or other verification acceotable to the aoencv is reouired to be Dresented when the permit is issued to verifv the Dropertv owner's siqnature party dress: ,4+ Signature of Property Owner Print name of owner L t ns l-f -?o @U BZo? oQd qav L. ilt\NO .,b 1 AUTHORIZATION OF AGENT TO ACT ON PROPERW OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the 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 prolect. Scope of Construction Project (or Description of Work) AqSq J B€omuto"l /Prolect Location or Address Name of Authorized Agent ---------------^ Ka*Lkz^ A - Nu o( 6- Address of Authorized Agent )3zq S B.oaol-- Phone Number of Authorized Agent:1lLl-o-t'71 ( I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Property Owner's Signature 7-T-20 print Name of own"r, 6a h b-r-1c 8c, verification acceptable to the agency is re-Note: A copy of the owner's driver's license, form nota zation, or other quired to be prcsented when the permit is issued to verify the Property owner's signature -2*