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dn. ,understand I may obtain more information regarding my obligations as an "employe/'from the lnternal Revenue Ser. vlEE, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 €00- 321-CSLB (2752) or,iwvw.cslb.ca.oov for more information about licensed contractors.-/) Zro I arn awae of and @nsent la an @ter-But*er building permt agptie<t tor in fiy nafie, and u&erstand thaa l am ttre party legally and financially responsible for proposed construction activity at the following ad- dress 1 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicafle laws and requirements that g @r l agree to notfy the issuer of th have provrdeo on tnls lorm overn Owner-Builders as woll as employers. is form immediately of any additions, deletions, or changes to any of th€ information I Licensed contractors are regulated by laws designed to protect the public. lf you conkact with someone who does not have a license, the Contractors' Slate License Board may be unable to assist you with any financial loss you may sustain as a result ol 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 hel( liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible fi1r verifying $,helh6r 6r nol those Conttactols are properly ,iceDsed and the status o, ,he,r workers' co.Drpe.Dsation inswa nce cotterege. Before a buildlng permit can be i6sued, this form must be completsd and signed by ths property owner and returned to the agency responsible for issuing the permit. ^rote: A copv of lhe Dropertv owner's drivet's licanso. fon nolarlza. tion, ot other varification acceptable to the adencv is reauired to be presented when the Dermit is issued to varifv the prooertv owne," s sldnature. Signature of Property Owner Date a,/oz/^ 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 personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply tor, sign, and file the documents necessary to obtain an Owner-Builder Permit for my pOect. Scope of Conslruction Project (or Description of Work) ProJect Location or Address:+,Q>to Name of Authorized Agent:G.rr^.',, GaJr\bavnY Address of Authorized Agent:S f.>7 Phone Number of Authorized Agent:7 rq - 33 oo10 I declare under penalty of perjury that lam the property owner for the address listed above and I personally filled out the above )ntfimabon and cefily its accuracy. Property Owner's Signature Ort".. /J Prinl Name of Owner: Note: A copy of lhe owner's driver's license, form notarizatlon, or other varllication acceptabls to the agency ls re- quPod ,o E prcseitd tuh€n the pemlt ls lssud ,o vslry the prqany owner's slgoarub.