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!(-S t 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. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at1-800- <br />321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. <br />1'(. rc.1 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 construction activity at the following ad-dress: IZL+ Ea,-<, rL 6li'€r- sr. SAtg-7 /f qxt,t- q7."L7- <br />3,( f lagreethat, as the party legally and financially responsible forthis proposed construction activity, lwill abidebyall <br />applicable laws and requirements that govern Owner-Builders as well as employers. <br />J,A p.l 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 someone who does not have a <br />license, the Contractors' State License Board may be unable to assist you with any flnancial loss you may sustain as a result of <br />a complalnt. 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 permit. ,Vote.' A copv of the propertv owner's driver's license, form notariza- <br />tion. or other verification acceptable to the aoencv is rcouired to be presented when the permit is issued to verifv the <br />proDe rtv ow n e r's s iqn atu re. <br />Date /o-t6-lg <br />Print name of Owner &-t ts Fe e-c+ <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 file the documents necessary to obtain an Owner-Builder <br />Permit for my prolect. <br />Project Location or Address <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 />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 presented when the permit is issued to verw the property owner's signature. <br />Signature of Property Owner <br />Scope of Construction Project (or Description of Work) <br />Property Ownels Signature: