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96 n I undersland I may obtain more information regarding my obligafions as an "employer" from the lnternal Revenue Service, the <br />'.[lnited States Small Business Administration, the California Department of Benefit Payments, and the California Division of lndustrial <br />Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or <br />www.cslb.ca.oov for more information about licensed contractors. <br />\ts^.&lO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />leqallv and financiallv responsible for proposed construction activitv at the following <br />ad"dreis, f oq'S.r.-t.C(:r\d t* q?--lo1.' <br />1 '1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />applicable laws and requirements that govem Owner-Builders as well as employers. <br />{Ar.l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />provided on this form. <br />Licensed 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 Ilnancial loss you may sustain as a result of a com plaint. <br />Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed <br />Contractor or employee of that individual or firm is injured wh ile working on your property, you may be held liable for damag es. lf you <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verirying 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. lvote,' A copv of the Drooeftv owner's driver's license. form notarization. or other <br />verification acceptable ,o the aqency is reduired to be presented when the permit is issued to verifv the property owner's <br />siqnature. <br />Signature of Prope(y Owner <br />..-....<- <br />print name of owne, - \(-.. (\.. <br />Date <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 />information and certify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner <br />Note: A copy of the owner's driyer's license, form notarization, or other verification acceptable to lhe agency is required to <br />be presented when the permit is issued to verily the property owner's signature. <br />PL ink:\irP5l lCoir nterActivitylAssern blyBills;Nolice 1o Prope(y Form <br />SANTA ANA CITY COUNCIL <br />mp!l dorosanta-ana oro <br />M3yor Pro Tem, Ward 2 <br />m ma rl .ez@sanla 'a.a oro <br />V ce.le Sarmrenlo <br />vsarmrerlolasa.ta-ane oro lsolorio@sanla-ana.oro <br />P David Benavdes <br />dbenavides@santa-ana.oro ivi eoasrasanla-a.aoro stin6ierorosanta ana oro <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 file the documents necessary to obtain an Owner-Builder Permit for my <br />pOect. <br />ScopeofconstructionProject(orDeScriptionofWork):