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\/ <br />-{* ,undersland I may obtain more information regarding my obligations as an "omployer" from the lnternal Revenue Service, the <br />tly'itpld States Small Business Administration, the California Department of Fenellt Payments, and the California Division of lndustrial <br />Atdidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or <br />for more information about licensed contractors <br />0. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />v nanciall v resoonsibD rJ.ble ro osed con ruction acti at the llowing <br />1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />ble laws and requirements that govern Owner-Builders as well as employers. <br />12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />ided on this form <br />icensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, <br />the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a com plaint. <br />Your only remedy against unlicensed Contractors may be in civil court. ltis also important foryou to understand that if an unlicensed <br />Contractor or employee ofthat individual or llrm isinjured while working on your property, you may be held liable fordamages. lfyou <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are <br />properly licensed and the status of their workers' compensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the <br />agency responsible for issuing the permit. A/ole,' A copv of the proDeftv owner's driver's license. form notarization. or other <br />verification acceotable to the aqencv is reouired to be presented when the oermit is issued to verifv the propertv owner's <br />siqnature. <br />Signature of Property Owner Date:\ t l'Z'17 <br />Print name of Owne <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the <br />following person(s) to act as my agent(s) to apply for, sign, and flle the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description of Work) <br />Project Location or Address <br />Name of Authorized Agent <br />Address of Authorized Agent;_ <br />Phone Number of Authorized Aqent: <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to <br />be presented when the permit is issued to verify the propefty owner's signature. <br />P L in k:W P5'1 lCounterActivity/Assenr blyB ills/Noti0e lo Pro perty Forn) <br />SANTA ANA CITY COUNCIL <br />moulidolOsanta ana.oro <br />Mayor ProTem Ward 2 <br />m man nez@sanla a.a.oro vsarm enlorAsanla ana oro isolono@sanla-ana oro <br />P. Dav d B.n6vides <br />dbenavides@sanla-ana.oro iviXe9es@!!da:a!!.q st na ero@santa-6na oro <br />Print Name of Owner: