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9-"ltnrc72 <br />licensed subcontractors and the number of structures does not exceed four within any calendar years, or all of the work is <br />performed under contract with a licensed general building Contractor. <br />-E-e. t understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any <br />financial or personal injuries sustained by any subsequenl owne(s) that result Irom any latent construction defects in the <br />workmanship or materials. <br />}f-g. I understand I may obtain more information regarding my obligations as an "employer" trom the lnlernal Revenue <br />Service, the United States Small Business Administration, the California Department of Benefit Payments, and the <br />California Division ol lndustrial Accidents. I also understand I may contact the Calitornia Contractors' State License Board <br />(CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. <br />-D,P f O. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am <br />the party legally and financially responsible for proposed construction activity at the tollowing <br />"dd'o"". <br />DP t t. I agree that, as the party legally and tinancially responsible for this proposed construction activity, I wlll abide by <br />allapplicable laws and requirements that govern Owner-Builders as well as employers. <br />NLf Z. t agree to notify the issuer of this lorm immediately of any additions, deletions, or changes to any of the <br />inlormation I have provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not <br />have a license, the Contractors' State License Board may be unable to assist you with any financial 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 lor <br />you to understand that il an unlicensed Contraclor 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 tor verifying whether or nol those Contractors are properly licensed and the status ol their workers' <br />compensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and <br />relurned to the agency responsible lor lssuing the permit. IVo,e.' A coov of the propertv owner's drlver's license. <br />torm notarizatlon. or other verlficatlon acceptable to the aoencv is reouired to be presented when the pemlt is <br />Signature of Property <br />Print name of Owner <br />Owner Date: <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution ol which I understand is my personal responsibility, I hereby authorize the <br />following person(s) to act as my agent(s)lo apply for, sign, and lile the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope o, Construction Project (or Description of Work) <br />Project Location or Address <br />Name oI Aulhorized Agent: <br />Address ot Authorized Agent <br />Phone Number o, Authorized Agent +5 <br />I declare under penalty of perjury that I am the property e Jor the address listed above and I personally rilled out the above <br />information and certily its accuracy. <br />Date: d.< lll,tMProperty Owner's Signature: <br />A{ <br />-Tff- <br />Print Name o, Owner: <br />Note: A copy ot the owner's drlver's form no tlon, ot other verlllcatlon dcccptdble to the dgency ls requlred to <br />be presented when the permlt ls lssued to verlfy the proryfiy owner's slgnature. <br />Pl-ink:WP51 /Ccunl6 AclvilyrAssemblyBrlrs jNo!.G !o Property Form 03 1 n.2016 <br />SANTA ANA CITY COUNCIL <br />moulido@sanLr-ana.orc <br />M chelo Maninez <br />Mayor Prc T6m, Wad 2 <br />mimertinez@enta-ana-or. <br />vicont€ Sarmi€nto <br />vsdmi6nto@s6nla-ana.oro isolorio@stnta-ana-oro <br />P. David Benavldss <br />db6nrvid6s@$nta-ana,ord ivillaoaBAsanta-ana..E stin6i6ro@sente-ana.oro <br />os/ /+ltq