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licensed subcontractors and the number of structures dobs not exceed lour within any calendar years, or all ol the work is <br />performed under contract with a licensed general building Cdntractor. <br />- u/L-A. I undersland as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable f or any <br />Iinancial or personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the <br />workmanship or materials. <br />V 9 I understand I may obtain more information regarding my obligations as an "employea'Irom the lnternal Revenue <br />Sbrvice, the United States Small Business Administration, the California Departmenl ol Benelit Payments, and the <br />California Division of lndustrial Accidents. I also understand I may contact the Calilornia Contractors' Stale License Board <br />(CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. <br />wL 10.1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am <br />lhe party legally and financially responsible for proposed construction activity at the following <br />address: /oog * ro& ). Beo*o".tA^l e**r*1A- q"?-bt <br />uuL ll.l agree that, as the party legally and financially responsible lor this proposed construction activity, I will abide by <br />all applicable laws and requirements that govern Owner-Builders as well as employers. <br />'rJL e.l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any ol the <br />information I have provided on this lorm. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not <br />have a license, lhe Contractors' State License Board may be unable to assist you with any financial loss you may sustain <br />as a result ol a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for <br />you to understand that il an unlicensed Contractor or employee ol that individual or firm is injured while working on your <br />property, you may be held liable lor damages. ll you obtain a permit as OwnerBuilder and wish to hire Contactors, you will <br />be responsible for verilying whether or not lhose Contractors are properly licensed and the status ol their workers' <br />compensation insurance coverage. <br />Berore a building permit can be issued, this form must be completed and signed by the property owner and <br />returned to the agency responsible tor issuing the per mit. /Vote; A coDv ot the DroDertv owner's driver's license, <br />form notarization. or other veritication acceDtable to aeency is required to be presented when the permit is <br />issued to <br />Signature of Property Owner Date:Zz> / <br />Print name of owner dorl O L <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I undersland is my personal responsibility, I hereby authorize lhe <br />following person(s) to act as my agent(s) to appiy for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description ol Work)$ae ?a*vs-<s <br />Prolect Location or Address /ooq + /@C P. bza*,*rtf <br />?{4J9€-cA- <br />Address of Authorized Agent Zt( tJ, Cl't+ ri 9Mt-+ *rJ+ C* nZlor <br />Phone Number ol Authorized Agent 7/( 647-oool- <br />ldeclare under penalty of perjury that I am the property er for the address listed above and I personally fjlled out the above <br />information and certify its accur <br />Property Owner's Signature Dale: 5 lc,/5 <br />Print Name of Owner: t .tot'l ( **y'c), Lll <br />Note: A copy of the neriticat'ron accepAOte to the agency is required to <br />be presented when the permit is issued to verify the property owner's signature. <br />SANTA ANA CITY COUNCIL <br />moulido@santa'ana oro <br />Mayor Pro Tem, Ward 2 <br />m man nez@sanla-ana oro <br />V ce.re Sam ento <br />vsarm ento@santa-ana.o.o isgbio@lrda:a!tuI <br />P. Oavrd Benavrdes <br />dbenav des@sanra'ana.oro illlelr!@ttolftet3.ca slinai6ro@sanla ana.oro <br />Name of Authorized Agent: