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licensed subcontractors and the number of structures does not exceed four wjthin an5' calendar years, or all of the work is <br />pertormed under contract wilh a licensed general building Contractor. <br />/ f\ a. t understand as an Owner-Builder if I sell the property tor which this permit is issued, I may be held liable for any <br />financial or personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the <br />workmanship or materials. <br />1_Lg. f understand I may obtain more information regarding my obligations as an "employer" lrom the lnternal Revenue <br />Service, the United States Small Business Administration, the Calilornia Department of Benefit Payments, and the <br />Calitornia Division ol lndustrial Accidents. I also understand I may contact the Calilornia Contractors' State License Board <br />(CSLB) at 1-800-321-CSLB (2752) or rvww.cslb.ca.oov lor more information about licensed conlractors. <br />7-ft .10. lam aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am <br />the party legal ly and financially,//n t r.,,/ I <br />responsibl q t'd'fif,-Tff '"ff t\)"4"" U trb' q Iollowing <br />address: /0 o\r.l <br />&r', I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by <br />all applicable laws and requirements that govern Owner-Builders as well as employers. <br />{_&l Z. I agree to notify the issuer of this lorm immediately of any additions, deletions, or changes to any ol the <br />information I have provided on this lorm. <br />Licensed contraclors are regulated by laws designed to protect the public. ll you contract with someone who does not <br />have a ticense, the Contractors' State License Board may be unable to assist you with any rinancial loss you may sustain <br />as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for <br />you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your <br />property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will <br />be responsible for verifying whether or nol those Contractors are properly licensed and the status of their workers' <br />compensation lnsurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and <br />returned to the agency responsible lor issuing the permit. Notei A copv of the Dropertv owner's driver's license, <br />torm notarization,or other verification acceDtable to the aoencv is reouired to be Dresented when the Dermit is <br />issued to verifv the Dro owner's sianature. <br />Signature of Properly Owner Date: O5 -/ O 1 9 <br />Print name of Owner 4 obi"l" R otz <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Nolice to Property Owner. the execution ot which I understand is my personal responsibility, I hereby authorize lhe <br />following person(s) to act as my agent(s) to apply for, sign, and tile the documents necessary to obtain an Owner'Builder Permil for my <br />project. <br />Scope ol 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 Agent <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 />inlormation and cerlify 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 verity the property owner's signature. <br />SANTA ANA C]TY COUNC L <br />4qrlr.d!@la!la:a!!!I! <br />l\rayor Pro Tem, Ward 2 <br />mman nez@sanra-ana.oro <br />v.ente Samienro <br />vsarm ento@sanla.ane oro solorio@sanla ana o.o <br />P. Oavd Benav des <br />d!e!a!ides@!a!E:s!i ivilledas@santa a.a.oro strnaiero@sanla ana.oro <br />Print Name o, Owner: