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9. I understand I may obtain more information regardin g my obligations as an 'employef from the lntemal Revenue Ser- <br />, lhe United Statas Small Business Administration, the California Department of Benefit Payments, and the Califomia Oivi-sion ol lndustrlal Accid ents. I also understand I may con tact the Califom ia Contractors' State License Board (CSLB) at 1{OO-321€SL (2752) or www.cslb.ca.oov for more information about licens ed contractors. <br />10. I am awa re ol and consent to an Owner-Builder bullding permit applied for in my name, and understand that I am the <br />at the following ad-legally and res for proposed conskuction <br />dress <br />1. I agre e that, as. the Party.legally and tinancially responsible for this proposed construclion activity, lwill abide by all <br />and requirements that govem Owner-Builders as well as employers.a e <br />I agree tonotiff the issuer of lhis form inlmediaiely;of ahi additions , deletions,.or changes lo any of tlie.informalion I <br />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 rinancial loss you may sustain as a result of <br />a complainL Your only remedy against unllconsod Contractors may be in civil courl. lt is also important for you to understand <br />that lf an unlicensed Contractor or employee of that individual or frm is iniured while worklng 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 thoss Contractors are propedy licensed and the stiatus of their workers' compensation insurance coverage. <br />Before a huildlng pormit can bs issuad, thls form must be completod and signsd by the property owner and returnod <br />to the agency aesponslble for lssulng tho p€rmlt. Note: A coov of the propetlv ownet's d ve,'s llcanse. form nota za. <br />or <br />propedv ownels slonaturo. <br />Signature of Property Owner Oate:2-- <br />Print 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 rollowing person(s) to act as my agent(s) to apply for, slgn, and lile the documents necessary to obtain an Owner-Builder <br />Permit for my proiecL <br />Scope of Construction Proiect (or Description of Work)SFc.Plo.s. rc\) <br />Prolect Location or Address ?03 <br />Name of Authorized Agent <br />Address ol Authorized Agent 3'd <br />Phone Number of Authoriz€d Agent:t <br />I d€clare under penalty of periury that I am the property owner for the address listed above and I personally filled out the above <br />infomation and certify its accuracy. <br />Property Owne,'s Signature:") <br />Print Name of Owner <br />Nota: A copy ol the ownels drlver's llconse, form notarlzatlon, or othet vertflcatlon acceptable to tha agency ls r* <br />qulrod to be presentad when the permlt ls lssued to vedfy the propetty owner's srgnature.