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the address listed above and I pe <br />L,il ,. , understand I may obtain more information regardingr,ny obl;gations as an "employe/ 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.qov for more information about licensed contractors. <br />-l[f.F f O. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />L*""5 Y ii'Ui\[X:'s "'€Ko"*ogilgictiv{ a[ the fo'ow2?id- cl a-r, r <br />. rlkS 1 1 I agree that, as the party legally and flnancially 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 />rl <br />L# t Z. t agree to notify the issuer of this form immediately of any additions, detetions, or changes to any of the information I <br />have provided on this form. <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 ermit. /Vote.' A copy of the propertv owner's driver's license, form notariza- <br />tion, or other veritication acceptable to the aqencv is required to be presented when the permit is issued to verify the <br />Signature of Property Owner Date ro/>-zlr7 <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 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 De ption of Work) <br />Pro.Ject Location or Address <br />Name of Authorized Agent: <br />Address of Authorized nt <br />Phone Number of orized Agent: <br />I declare under nalty of perjury that I am the property owner nally filled out the above <br />information a certify its accuracy <br />Prope Owneis Signature te <br />P nt Name of Owner <br />Note: A copy of the owner's driver's licensq form notarization, or other tion acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the property o s signature. <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 financial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civil cou(. 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 />propertv owner's s ionatu re.