10193450 - Permit (2) - Laserfiche WebLink

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the party I address: all and financi res sible for proposed construction the folloeactivitv alrA, A/ta SS-,,1 I agree that, as the party legally and linancially responsible lor this proposed construction activity, I will abide by -all applicable laws and requiremenls that govern Owner-Builders as well as employers. S-!f Z. I agree to notify the issuer of this lorm immediately of any additions, deletions, or changes to any of the inlormation 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 result ol a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand lhat if an unlicensed Contractor or employee of 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 verilying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. torm notarization, or other verification acceDtable to the agency is required to be presented when the permit is o issued to veritv the Dropeiv owner's sionature Signature of Property Owner Date:7-oz Print name of Owner liiRZ,tn 3t4*)f-a',,o 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 ,ollowing person(s) to act as my agent(s) to apply for, sign. and lile the documenls necessary to obtain an Owner-Builder Permit for my project. Scope of Conslruction Project (or Description of Work) Projecl Location or Address Name of Authorized Agent Address ol Authorized Agent ldeclare under penalty of perjury lhal I am the property owner lor the address listed above and I personally filled oul the above inlormation and certify its accuracy. Property Owner's Signature Dale Print Name ol Owner Note: A copy of the owner's driver's license, lorm notarization, or othet veritication acceptable to the agency is required lo be prcsented when the permil is issued to verily the prcperty owner's signature. SANTA ANA CITY COUNCIL Mayoi Pro Tem. Wad 2 lBlr.,o@snta.ana oro vsa'm,enb@sa.ra a.a o.o Eoloro@snta.ana oro d5â‚¬nav des@santa.ana oro Mlleas@snla-ane oro sxnabro@sanla.ana o.. licensed subcontractors and the number of structures does not exceed lour within any calendar years, or all of the work is performed under contract with a licensed general building Contractor. >\8. I understand as an Owner-Builder ll I sell the property lor which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owne(s) that result lrom any latent construclion defects in the workmanship or materials. b.) ,g I understand I may obtain more inlormation regarding my obligations as an "employer" from the lnternal Revenue Service, the United Stales Small Business Administration, the California Department of Benefit Payments, and the Calilornia Division of lndustrial Accidents. I also understand I may contact the Calilornia Conlractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors.(--^ >>;10. I am aware of and consent to an OwnerBuilder building permit applied lor in my name, and understand that I am Belore a building permit can be issued, this torm must be completed and signed by the property owner and returned to the agency responsible for issuing lhe permit. /Vote; A coDv ot the proDertv owner's driver's license. Phone Number ol Authorized Agent: