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- Y 9. I understand I may obtain more information rogarding my obllgalions as En 'employ€/ from th6 lntemal Rovenus Se(- <br />vlce, the United States Small Business Administration, the California Department of Eenallt Payments, and the Califomia Divi- <br />sion of lndustrial Accidents, I also undsrstand I may contact th€ California Contraclors' State Llcense Board (CSLB) at l -BOO- <br />32.1-CSLB (2752) or www.cslb.ca.oov tor more information about licens8d contractors. <br />\ 10. I <br />"rn "ware <br />of and mnsent to an Owner-Bullder buildlng pemit appll€d for in my namB, and understand that I am the <br />party legally and flnancially responsible for propos6d construction activlly at ti6 folbwing ad- <br />dr6ss: <br />\.. <br />1.1.. l.agree that, as the party legally and flnancially responsible for thls proposed construction activity, I will ablde by all <br />applicable laws and requlrements lhat govern Owner-Builders as well as employers. <br />\ 12. lagreeto notlfy the issuer of thls lorm immedlately of any additions, doletions, orchangesto anyofthe informa on I <br />have providad on this form. <br />Licensed conbactors are regulated by laws designed to prot€ct the public. lf you contract with somoono who does not have a <br />license, the Contractors' State Licsnse Board may be unable to a66lst you wlth any financial loss you may sustain as a result ol <br />a complaint. Your only remedy againsl unlicensad Contractors may bB in civil court. lt is also important for you to understand <br />that if an unllcens€d contractor or employee of that individual or flrm is injured while worklng on your property, you may be held <br />liable for damages. lf you oblain a perrnit as owner-Builder and wish to hire Contactors, you will be responsibG for verifying <br />whether or not those contractors are properly licens6d and the status of their workors' compensation insurance coverage. <br />Boforo 8 bulldlng permlt can be ls6ued, thls form must b <br />to the agency 106ponslblo for lssulng tho permll, lrote.. <br />I completod and slgned by tho proporty owner and returned <br />A copy of the Drdoaft{ owner's drlve,'s license. fotm notarlza- <br />fr/zr/e <br />p rop e ttv ow n e f s s ld n atu re. <br />Signature of Property Ownet <br />Print name of Owner Vr <br />Scopo of Construction ProJect (or Description of Work)EE- g-a-r? <br />Date <br />e4 <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Own6r, the axecution o, which I undeBtand is my personal responsibility, I hBreby authorize <br />the following person(s) lo act as my agent(s) to apply for, slgn, and file the documents necessary to obtain an Owner-Builder <br />Pormit for my project <br />Project Location or Address:la:, x.l. -rep^.we.- sr. grr-^ r'0+"-C^ <br />Name of Authorlzgd Ag€nt: <br />Address of Authorizod Ags <br />Phone Number of Authorized Agenl <br />I declale under penalty of per.iury th m the property own6r for the ss listed above and I personally lllled oul he above <br />information and certify its accura <br />Da*: /o'22 nProperty Owne/s Slgnature: <br />Print Name ot Owner:\./l t t <br />Note: A copy of tho ownelg ddvels llcense, form notalization, or othsr verlticatlon acceptable to the agency ls t* <br />qulred to ba presented whsn the permlt ls lssued to vortty the property ownst"s slgnature,