10195219 - Permit - Laserfiche WebLink

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licensed subcontractors and the number of structures does not exceed four within any calendar years, or all of the work is performed under contract with a licensed general building Contractor. f'-Na. f understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any flnancial or personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the workmanship or materials. /^t ^ YJa g t understand I may obtain more information regarding my obligations as an 'em ployer' from the lnternal Revenue S-ervice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division 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.qov for more information about licensed contractors. (41 O. I am aware of and consent to an Owner-Builder building permit applied for an my name, and understand that I am the party legally address: and financiall y responsible for proposed constructio ivity t the followi ng L)\ h--)\--/\-o-\v'\G! Signature of Property Owner )?*"*"rt*: s-2-lt' Print name of Owner a 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 lollowing 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 project. Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Aqent: 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 Owner's Signature Date Note: A copy of the owner's driver's license, form notarization, or other verif,cation acceptable to the agency is required to be presented when the permit is issued to verify the propedy owner's signature. !! .rr \'\'ta r a.,.i.r'Ar:1! At:.r4,!i ,. fLi....:. p.:i-.:: Ii_- ]r lri :r: -5 SANTA ANA CITY COUNCIL moulido@santa-ana oro Mayor Pro Tem, Wa.d 2 miman ne2@sanla-ana.oro vicen!e Samiento vsamrenbrosanla-ana oro iso oriorosanla-ana.oro P Dav,d Benavides dbenav des@sanla€na.oro ivilleoas@santa-ana.oro shnaero@santa ana oro issued to verifu the Dropertv owner's sianature. R,\U\L, Print Name of Owner: (Ar,1 I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. VD_irr.l 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 financial 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 liable 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. Note; A, copv of the oropertv owner's driver's license, form notarization. or other verification acceptable to the adencv is required to be presented when the oermit is