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) t ,45. t understand I may oblain more information regarding my obligatiors as an "employer" from the lnternal Revenue Service, the <br />United States Small Business Administration, the California Department of Beneflt Payments, and the Califomia Division of lndustrial <br />Accidents. lalso understand lmay 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 />-\-L!21 <br />legally <br />0. I am aware of and consent to an Owner-Builder buildin g permit applied for in my name, and understand that I am the party <br />ial respon SI e for propose ction acti ity at the folad <br />address <br />jLZ,.l agree that, as the party legally and f nancially responsible for this proposed mnstruction activity, I will abide by all <br />applicable laws and requirements that govem O\,vner-Builders as well as employers. <br />TUn.l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of lhe information I have <br />provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someonewhodoes not have a license, <br />lhe Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a com plaint. <br />Youronly remedy against unlicensed Contractors may be in civil court. ltis also important for you to understand that if an unlicensed <br />Contractor or employee ofthat individual or firm is injured while working on your property, you maybe held liable for damages. lf you <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verii/ing 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. i/ore: A copv of the prcDertv owner's driver's license. form notarization, or othet <br />re rm issued lo the r' <br />sionaturc. <br />r fc.iv 2/- Zzi/ <br />Signature of Property Owner Date <br />Print name of Owner It <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 flle the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description of Work) <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 <br />Note: A copy ol the owner's driver's license, form nolarization, or other verification acceptable to the agency is required to <br />be presented when the permit is issued to yerify the propefty owner's signature. <br />F.likr,,"JP51 C!rnl?:A.jil,ri! Assi,n'f,l!B lls N:tlce 1o Proi.,r'a(,,,Fornl <br />SANTA ANA CITY COUNCJL <br />npUrdo@san!a€na do <br />Maylr Pro Tem. Wa.d 2 <br />nrrodrnez@sanrE .na oo <br />llcente samento <br />Bamiento@sant -ana oro Eal!!!@r!!l!:a!a.s9 <br />P Dav'd Ee.audes <br />dberuvd6sOsanla-a.a do rrrle.sasanl, .na oro sl narero. sa.la 8na oro <br />-n, <br />AUTHORIZAIION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Project Location or Address: _ <br />Date: <br />Print Name of Owner: