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licensed subcontractors and the number of structures does not exceed four within any calendar years, or all ol the work is <br />performed under contract with a licensed general building Contractor. <br />i/'i a t understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any <br />fin'arrcial or personal injuries sustained by any subsequent owner(s) that resuli from any latent construction delects in the <br />workmanship or materials. <br />'D'l S. t understand I may obtain more inlormation regarding my obligations as an "employer" Irom the lnternal Flevenue <br />Service, the United States Small Business Administration, the California Department of Benefit Payments, and the <br />Calilornia Division of lndustrial Accidents. I also understand I may conlact the California Contractors' State License Board <br />(CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. <br />\/l lO.l am aware ot and consent to an OwnerBuilder building permit applied for in my name, and understand that I am <br />the party I <br />address: <br />ally and f ina nciall res onsible forv pro constru tlon act at theA--- <br />llowino(4ivitylo <br />,2E'l'1. I agree that, as the party legally and linancially responsible for this proposed construction activity, I will abide by <br />all applicable laws and requirements that govern Owner-Builders as well as employers. <br />'l/ \ P. I agree to notily the issuer of this form immediately of any additions, deletions, or changes to any of the <br />intormation I have provided on this form. <br />Licensed contractors are regulated by laws designed to protecl the public. lf you contract with someone who does not <br />have a license, the Contractors' State License Board may be unable lo assist you with any financial loss you may sustain <br />as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important lor <br />you to understand that if an unlicensed Contractor or employee ol that individual or firm is injured while working on your <br />property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will <br />be responsible for verilying whether or not those Contractors are properly licensed and the status of their workers' <br />compensation insurance coverage. <br />Before a building permit can be issued, this form musl be completed and signed by the property owner and <br />relurned to lhe agency responsible lor issuing the permil. Note: A copv of the Dropertv owner's driver's license, <br />form notarization or other verification ble to the /s uired lo be the it iscn <br />Signatu re of Property Owner Date: 1 3- l7- <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, lhe execution ol which I understand is my personal responsibility. I hereby authorize the <br />following person(s) to acl as my agent(s) to apply for, sign, and lile lhe documenls necessary to obtain an Owner-Builder Permit for my <br />Scope ol Construction Proiect (or Descriplion of Work) <br />Projecl Location or Address <br />Name ol Authorized Agent <br />Address of Authorized Aqenl <br />Phone Number ol Authorized Agenl <br />ldeclare under penalty ol perjury that I am lhe property owner lor the address lisled above and I personally filled out lhe above <br />inlormation and certily its accuracy. <br />Property Owner's Signature Dale <br />Print Name ol Owner <br />Note: A copy ol the owner's driver's llcense, lom notarization, or olher verilication acceptable to lhe agency is required lo <br />be presented when the permit is issued to verify the propeny ownet's signature. <br />SANTA ANA CITY COUNCiL <br />6p!l'do@sanla.ana.oro <br />Mayor Pro Tom, $/ard 2 <br />miman ne2@sanla-ana.oro vsa,m'e.ro@sa.ra.a.a o,o Boloro@sanla-an. or. <br />P. Oav'd Benavdes <br />@Elalrie@l9llt,illrrrc jv'le9as@sada:tui slna'ero@santa-ana.oro <br />Print name of Owner fhntr,-t,t ?t--I ra-2./\,-..--