20163641 - Permit (2) - Laserfiche WebLink

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licensed subcontractors and the number ol structures does not exceed lour within any calendar years, or all of the work is perfo under contracl with a licensed general building Contractor understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construclion defects in the workmanship or malerials. i1/ice, t I understand I may obtain more inlormation regarding my obligations as an "employer" from the lnternal Revenue he United States Small Business Administration, the Calilornia Department of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contact the Calilornia Contractors' State License Board (CSLB t 1-800-321-CSLB (2752) or www.cslb.ca.oov lor more inlormation about licensed contractors. am aware ol and consent to an OwnerBuilder building permil applied for in my name, and understand that I am pa rty legally and financially responsible for proposed construction activity at the following address I agree that, as the party legally and Iinancially responsible for lhis proposed construction activity. I will abide by icable laws and requirements that govern Owner-Builders as well as employers I agree to notify the issuer ol this form immediately of any additions, deletions, or changes to any of the ormation I have provided on this form Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, the Conlractors' State License Board may be unable to assist you wilh 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 ol 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 for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Belore a building permil can be issued, this lorm must be completed and signed by the property owner and returned to the agency responsible lor issuing the pe rmit. ,Vote. A copv ol the properlv owner's driver's license, lorm notarizalion, or other veritication acceptable to the aqency is required to be presgnled WIE|I the peun4E Signature of Property Owner oa:r': 1:/2:/ a Prinl name ol Owner ,7ro--/ zl /-Z-.-; AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner. lhe execution ol which I undersland is my personal responsibility, I hereby authorize the ,ollowing person(s) to acl as my agent(s) lo apply lor, sign, and lile the documenls necessary to obtain an O\,vner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Projecl Location or Address *f zU. ZzsZ.t â‚¬r'- <H Name of Authorized Agent Phone Number ol Authorized Agent ldeclare under penalty ol perjury that I am the property owner for the address listed above and I personally filled oul the above information and certily its accuracy. Property Owner's Signature Date Note: A copy ot the owner's driver's license,lorm notarizalion, ot other veritication acceptable to the agency is required to be prcsented when the pemit is issued to verily the propeiy ownet's signaturc. SANTA ANA CITY COUNCIL moul do@santa-ana.oro Mayor Pro Tom. Ward 2 mrman'nez@sa.ta.ana-oro Vrcâ‚¬nte Sarmonro vsamEnto@sanra-ana.oro 60ldro@sanra-ena oro P Oavid Benav'des dbenavrdes@santa.a.a.oro v(leoas@sanla-ana.oro st naâ‚¬ro@sanla-ana.oro Print Name ol Owner: Address ol Authorized Agent:_