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lic{nsed subcontractors and the number of slructures does not exceed four within any calendar years, or all ol the work is pedfermed under contract with a licensed general building Contraclor.' t,1, V',e. t understand as an Owner-Builder if lsell the property ror which this permit is issued, I may be held liable lor any fi ncial or personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the rkmanship or materials 9. I understand I may obtain more inlormation regarding my obligations as an "employer" from the lnternal Revenue S ce, the United States Small Business Administration, the California Department ol Benefit Payments, and the Calilornia Division ot lndustrial Accidents. I also understand I may contact the California Contraclors' State License Board (c LB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more intormation about licensed contractors 10. I am aware of and consent to an Owner-Builder building permit applied lor in my name, and undersland that I am rty legally and f inanciall yr onsible {or proposed constructio n activi ty at the f ollowing 4a"C4 11. I agree that, as the party legally and financially responsible for this proposed constructlon activity, I will abide by a plicable laws and requirements that govern Owner-Builders as well as employers 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the tn rmation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public- ll you contract with someone who does not have a license, the Contractors' State License Board may be unable to asslst 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 unlicensed 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 Ior verilying whether or not thoss Contraclors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this torm must be completed and signed by the property owner and returned to the agency responsible tor issuing the permit, ,Vote.'A coDv of the DroDertv wncr's drivcr's liaense- lorm notarization or other n a uired to be ted when the Signature of Property Print name of Owner Owner ctt LLQat", iv b ,, L ->" 11 \^ ) o Al C-l< h- AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding lhe Notice to Property Owner, the execution of which lunderstand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply lor, sign, and file the documents necessary to obtain an Owner-Builder Permit lor my Scope ol Construction Project (or Description of Work)?t-\it9 6.0 ? LA$! Project Location or Address - /oo8 p. +l q - 7.r ?- Zoc) B ldeclare under penalty of perjury that I am the prope owner for the address listed above and I personally filled out the above inlormation and certily its accuracy Date: \,- )-o tclb w Note: A copy of the owner's driver's license, lorm notarization, or other veritica tion acceptable to the agency is required to be presented when the permit is issued to verily the property owner's signature. r,l.r 9/P5r alc|.k A.r,rltrL.srrblrli sf.lor.€,r.Pr.pe,irF. r.l,:1,1iiia SANTA ANA CITY COUNCIL moulido@santa-ana oro lMayor Pro Tern. Ward 2 m martrnez@santa a.a oro Vrcenle Sarmienlo vsarmlento@santa'ana.oro dbenavrdes@santa ana oro vlleoas@santa ana oro srinaiero@sanra-ana oro issued to verifv the Dropertv owner's sionature. ,-l I Name ol Authorized Aoenl: -tfirv P y @Nr€cA- Address ol Authoriz ea egent: 3/r h/ 41-++ < r t ,4,.J7-a A-J * c 11' q1 +o I Phone Number ol Authorized Agent: (Property Owneas Signature: Print Name of Owner: isolorio@sanra-ana.oro