101102450 - Permit - Laserfiche WebLink

Home Browse Search

2, ,understand I may obtain more information regarding my obligations as an ''employer' from the lnternal Revenue Ser-vI6tne Unlted States Small Business Adminiskation, the Califomia Department of Benefit Payments, and the Caliicrnia Divi- sion of lndustrlal 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, --l &ro I afi awae ot and acrs€nt to an owner-Euher butfiing permit affid for in my name, and understand tiat I aftI tlt€ party legally and financially responsible for proposed construction activity at thE following ad- dress 11. I agree that, as lhe party legally and finanoially responsible lor this proposed construction activity, I will abide by all govem Owner-Builders os well as amployers this firrm rmrnaiialely of any addifions- delefians, ot chdnges to any ot the infomahon I Ltcensed contractors are regulated by la\ivs designed to protect the public, lf you contract with someone who does not have a ltcense, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result c a complaint. Your only remedy against unlicensed Contractors may be in civil court lt ls also important for you to understand that if an unlicenscd Contractor or employee of that individual or firm is injur€d whils working on your property, you may be hel liable for damages. lf you obtain a permit as Owner€uilder and wish to hire Contac'tors, you will be responsible for verifying u,h6&her ry not lh6\se CoDracrars ere p,roperry licensed and the status ol tl]€.it wo*ets' cotnpensatkn insuan@ eowego. Belore a building permit can be iasued, this form must be completed and signed by the property owner and rsturned to the agency responslble for fssulng the permit. Itlote.' A copv of thc orooefiv ownor's d vat's license, lom nota 22 tion, or other verlfication acceotable to the adencv ls requlred to be prasented when the oermlt ls lssued to verltv the grooertv gwnef s sldnatu re, o,E /2/oz/2o/?srgtrrture of Propgny owner Print name of Owner AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my porsonal responsibility, I hereby authorize Ule ,olrowing personls) to ect 8s my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner€uilder Permit for my projact. Scope of Conslruction Project (or Description of Work) Prolect Locatloo or Address q 10 Name of Aulho,'Led y'gent:Terrv Garrbav Address of Authorized Agent:3b03 W. 5+i sl slNrA *NA, cA 4>t1 -/--- --1 Phone Number of Authorized Agent:7lq- 33t- oolo I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the abov intofip q, eN cetfiy tlse'5.urzcy. Propeny Ownef s Signature:aae. /J Print Name of Owner. Note: A copy ol the owner's drivsr's license, form notarlzatlon, or other vcrlficatlon acceptable to the agency is ro-qaldbbFq*Nt'Mtup#lelsstdtovully toptryerry Dvt ryb dgt Etu e