105105107 - Permit - Laserfiche WebLink

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10 I am aware of and consent to an Owner-Build building perm pplied for in my n me. and understand that lam the pa egally and financiall v res sible for proposed co truction activi the following 210(3 F I agree that, as the party legally and financlally responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers 12. I ree to notify the issuer of this form immediately of any additions. deletions, or changes to any of the information I ave prov ided 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 unllcensed 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 pe rmit. Note.'A copv of the Dropertv owner's driver's license. form notariza- tion or other verification acc ble to the ,s uired to be resented when the it is issued to verif the Signature of Property Owner Date I 0 7 Print name of Owner qLe n 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, slgn, 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 Agent Address of Authorized Agent Phone Number of Authori Agent: I declare under alty of perjury that I am the prope(y owner for the a ss listed above and I personally filled out the above informatio d certify its accuracy Property Owner's Signature Date Print Name of Owner: L-L l understand I may obtain more lnformation regarding my obligations as an "employer" from the lnternal Revenue Ser- vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- sion of Industrial 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. dress prope rtv own er's s io n atu re. 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 issued to verify the propefty owner's signature.