20163629 - Permit (2) - Laserfiche WebLink

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f) 9. I understand I may obtain more information regarding my obligations as an "employer" Irom the lnternal Revenue Service. the United States Small Business Administration. the Califomia Department of Benefit Payments, and the Califomia Division of lndustrial Accidents. lalso understand lmay contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors.:til.-v 10. I am aware of and consent to an OwnerBuilder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the foilowing 4nrqtilSS '11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applipable laws and requirements that govem Owner-Builders as well as employers.1. hl.V '1 2. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 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 Contractors' State License Board may be unable to assist you with any linancial loss you may sustain as a resull 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 damag es. 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 lhe status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. /Vore. A copv of the propertv owner's driver's license, form notarizalion, or other siqnaturc. Signature of Property Owner Date Print name of Owner YLi AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the 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 project. Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent: Address of Authorized Agent: Phone Number of Authorized Agent I declare under penalty of perlury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Properly Owner's Signature Date Print Name of Owner: Note: A copy of the owner's driver's license, fom notarization, or other verification acceptable to lhe agency is rcquired to be presented when the permit is issued to verify the propefty owner's signaturc.t'-l:( ,'. Pa'l C r!iritrici . ii, iss(:nrDivB I s I'lci cc to Pri)ir.rtv Form SANTA ANA CITY COUNCIL mouhdolosanla-ans oro Mayd Pro Tem Ward 2 mrmartrnâ‚¬u lasanla 6na so \sa.m,enr.6sarta ana o..Edp!!(l!a!El!i-Q!c dbenav,desG.santa ana oro v' eoasrasa.ta ana oro slrnaeroosa.la ana oro ty .t