10296788 - 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. __{O_A f understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any findncial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 4 g. t understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, 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 Conlractors' State License Board (CSLB) at 1 -800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. PO the pa 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am rty legally and financially responsible for pro osed construction activity at the following address It ! I t . 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. tt lt t Z. t agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the infdrmation 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 Iicensed and the status of their workers' com pensation 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 p ermit. Noter A copv of the propefiy owner's driver's license, form notarization, or other verification acceptable to the aqencv is required to be sented when the Dermit is Signature of Property Owner Print name of owner ltl N ) tt; Date v6 yA") 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 file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) t'1""'- '- <t-f Project Location or Address 't*^r tE r.tr"/Vi U ILP\ircD l*utl- 6 Name of Authorized Agent:&'ck.r."\ C-*t-'-'a ,??t'4 Address of Authorized Agent i.\q]. s !i (-trrto&t s trrulrr fyNo- q Phone Number of Authorized Agent (t tt -,.2oC I declare under penalty of perjury that I am the property owner for the address listed above and I personally lllled out the above information and certify its accura Property Owner's Signature Print Name of Owner: Date Note: A copy ofthe owner's dri license, form notariz ation, or other verification acceptable to the agency is required to be presented when lhe permit is issued to vefify the propedy owner's signature- Plr.r yJ p5i ,C.r.le_A.!,.! A3.ei:,5 i:NJl.: ic P..;?ty F r.- a? ir:(,16 SANTA ANA CITY COUNCIL MguelA. Pulido Mlchele Marlinez vicente Samle.to Jose Solorio P Oavid Benavides Mayor MayorProTem, ward 2 ward 1 Wad 3 ward 4 -oJrroo@saita-a.a o.o - -ari 1ez@sanra a.a.o.o 6anre^to@ssrra.ana o,o 'sorolo@salra-ana orc doena oes@sarra dna o o ivilleoas@sanla-ana.oro sllnalero@sanla an6 oro issued to verifu the propertv owner's sionature. elrl,l\{t-A ^/ Dlto