Laserfiche WebLink
l,lZ/-S I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Ser- <br />vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- <br />sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- <br />321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. <br />t l4-lO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />party legally and flnancially_responsible for proposed_consrruction activity a(the fgllowing ad-ess /.,/G 5.. ( wJttsr *zu ).-/-. /4* U- ) z 7c t7- <br />ilJt <br />-11. <br />I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />applicable laws and requirements that govern Owner-Builders as well as employers. <br />Aa e I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />have provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someonewhodoes not have a <br />license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand <br />that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held <br />liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not those Contractors are 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 <br />to the agency responsible for issuing the p eamit. /Vote; A coDv of the DroDertv owner's driver's license, form notariza- <br />tion. or other verification acc eDtable to the adencv is reouired to be Dresented when the Dermit is issued to verifv the <br />itr/ <br />lll,qwr /4 " l/a'sqgPrint name of Owner (L <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize <br />the following person(s) to act as my agent(s) to apply for, sign, and flle the documents necessary to obtain an Owner-Builder <br />Permit for my project. <br />Scope of Construction Project (or Description of Work) <br />Project Location or Address <br />Address of Authorized Agent: <br />Phone Number of Authorized Agent <br />I declare under penalty of per.lury that I am the property owner for the address listed above and I personally fllled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner: <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- <br />quired to be presentad when the permit is issued to verffy the propefty owner's signature. <br />propertv owner's sio natu re. <br />Signature of Property Dare / / /2.r./2,a,/7,/ <br />Name of Authorized Agent: