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t-Lg I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Ser- <br />vic6, the United States Small Business Administration, the California Departrlent pf Benefit Payments, and the California Divi- <br />sion of lndustrial Accidents. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at1-800- <br />321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />eLtparty le <br />dress: <br />0. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />gally and fin a nciall v re pon sible for ro nstruction activi the owing ad- <br />bl_1l.1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />app(icable laws and requirements that govern Owner-Builders as well as employers. <br />/a! <br />hatre <br />12. I agree to notify the issuer of this form immediately of any addltions, deletions, or changes to any of the information I <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 <br />license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand <br />that if an unlicensed Contractor or employee of that individual or flrm is inlured while working on your property, you may be held <br />liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not those Contractors are 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 owner and returned <br />to the agency responsible for issuing the permit. lrofe: A copv of the propertv owner's driver's license. form notariza- <br />,s ired to be resented when the it is issued fo <br />DroDertv owner's sionatu re. <br />Sig nature of Property Owner caL Date: I <br />Print name of Owner ,,vtA {LLo-,v//esc*5 <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 <br />the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder <br />Permit for my project. <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 perJury that I am the property owner for the address listed above and I personally fllled out the above <br />information and certity its accuracy. <br />w ^/-r^ ?,4,.^Date tt les// r <br />print Name orowne. /vt A L / o-t y//rSUS <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the propefty owner's signature. <br />a_ <br />ScopeofConStructionProject(orDeScriptionofWork): <br />Property Owneis Signature: