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lfutt ,undersland I may obtain more information r."grting ,y oOtig"tions as an "employer" from the lnlernal Revenue Service, the <br />'United States Small Business Administration, the Califomia Department of Beneflt Payments, and the California Division of ln dustrial <br />Accidents. lalso understand lmaycontactthe Calilornia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or <br />www.cslb.ca.qov for more information about licensed contractors. <br />d-4,0., am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />legally and financially responsible for proposed construction activity at the following <br />address: <br />il4,,.I agree that. as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />rapplicable laws and requirements that govern Owner-Builders as well as employers. <br />fflfi2.t ugr"" ro notity the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />'piovided 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 lo assist you with any linancial loss you may sustain as a result of a complaint. <br />Youronlyremedy 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 while working on your property, you may be held liable for damages. lf you <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying 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. Note: A coDv of the properlv owner's driver's license. form notarization. or other <br />verification acceptable to the aoencv is reouired lo be presented when the permit is issued to verifu the propertv owner's <br />siqnature, <br />o*n", /-/errb"rffu^"-t1Signature of Property <br />Print name of Owner <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 />project. ,/ <br />Scop" of constr,.lion Project (or Descri ption ot wo*1, 7 ^ I 7 ' I 1 <br />Project Location or Address <br />Name of Authorized Agent: <br />3oog w LUl,Lon 5 I SA vrTA ,4 na C Alllol <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 fllled out the above <br />inlormation and cerlify its accuracy <br />Date 1-t1- t7Property Owner's Signature r/a <br />Print Name of Owner <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is reguired to <br />be presented when the permit is issued to verify the propefty owner's signature. <br />PLin(r,r'P51 Ceunt7rAalr! 1! q:scnr!rl;3lls'Nci ar la Priri,.rli Fo'.nr <br />SANTA ANA CITY COUNCIL <br />nouldc@sBnrr-3ru o.E <br />Mayor Pro T6m Ward 2 <br />m manr.e2osa.€.a6a do <br />Vcenre S€d'enlo <br />6am'enro6sant -an8 do Eg9lqerelEa!3-e{! <br />P Oavd Benaudes <br />!!e!!r4!e!@r41a:!!!49 ulrege'@!!llil:r!!-q!