126 E Dyer Rd Unit# A - Misc. Permit

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1/-8 I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any fihalcial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workma ip or materials. nderstand I may obtain more information regarding iry oOtiiations as an "employef' from the lnternal Revenue., lu e the United States Small Business Administration, the California Department of Benefit Payments, and the Cal ia Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB)/at 1-800-321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors r,..,10 tFre party I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am legally and finan ciallv L.1) responsible for propos ed truction activ at the,lc,)followingcons 5uaddress:C 0r- la I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the on 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 wath any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that 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 verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the pel it. ,Vore.' A coov of the Drooertv wner's driver's license. form n other a ,s d when the issued to the Drooeftv own sianature. . I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by able laws and requirements that govern Owner-Builders as well as employers. ,14 Signature of Property Print name of Owner Owner Date lL-s'tJ u l,r-rG"r+\ AUTHORIZATION OF AGENT TO ACT ON PROPERW OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sjgn, and file the documenls necessary to obtain an Owner-Builder Permit for my project. ScopeofconSlrUctionProjecl(orDescriptionofWork): Project Location or Address: Name of Address Aiithorized Aoenti of Authorized Age nt: Phone Number of Authorized Agent I declare under penalty of perjury that I am the property owner for the address listed above and I personally lilled out the above information and certify its accuracy. Property Owner's Signature Print Name of Owner: Date Note: \A copy of the owner's driver's license, form notarization, or other verification accepaable to the agency is required to be preqented when ahe permit is issued to vctify the propefty owner's signature. PLink:WP51/Counter Activity/Assembly Bills/Notice to Property Owner & Authorization Fotm 06-2012