30341892 - Permit (2) - Laserfiche WebLink

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1/ g I understand I may obtain more information regarding my obligations as an "employef from the lnternal Revenue Ser- vice, the United States Small Business Administration, the California Department of Benefit Payments, and the Californaa Divi- sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- 321-CSLB (27 52)or www.cslb.ca.qov for more information about licensed contractors JlulO I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the dary legally and financially responsible for proposed construction activity at the following ad- dress: t'y' ll.lagree that, asthe party legally and flnancially responsible forthis proposed construction activity, lwill abidebyall dpplicable laws and requirements that govern Owner-Builders as well as employers. 1l'lZ.tagreetonotifytheissuerofthisformimmediatelyofanyadditions,deletions,orchangestoanyoftheinformationI 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 civil 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 laable 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. /Vofe : A coDv of the DroDerTv owner's driver's license, form notariza- tion, or other verification acceptable to the aqencv is reduired to be presented when the permit is rssued to verifv the property owner's siqnatu re Signature of Property Owner Date: l_ -3 -la>D Print name of Ownet I uoat ;i^./.. AUTHORIZATION OF AGENT TO ACT ON PROPERTY 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 flle the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Pro.iect (or Description of Work) Project Location or Address Name of Authorized Agent: Address of Authorized Agent: Phone Number 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 Ownef s Signature Date Print Name of Owner: Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- quired to be presented when the permit is rssued to verify the property owner's signature. aZ---a-rt'