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licensed subcontractors and the number of structures does not exceed four within any calendar years, or all of the work is <br />performed under contract with a licensed general building Contractor. <br />_/-A t understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any <br />financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the <br />workmanship or materials. <br />r' S I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue <br />Service, the United States Small Business Administration, the California Department of Benefit Payments, and the <br />California Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board <br />(CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. <br />/ lO.I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am <br />the party legally and financially responsible for proposed construction activity at the following <br />address: tq trt ELS{ llth S{r c--l -Sg.ile,A- Scn.la Aoc <A q2.?6.S <br />- 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by <br />all applicable laws and requirements that govern Owner-Builders as well as employers. <br />r' lZ.l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the <br />information I 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 <br />have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain <br />asaresultof a complaint. Youronly remedy against unlicensed Contractors maybe in civil court. ll is also important for <br />you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your <br />property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will <br />be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' <br />compensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and <br />returned to the agency responsible for issuing the Permit. /Vo(ej A coDv of the oroDertv wner's driver's license- <br />form notarization, or other verification acceptable to the aqencv is reduired to be presented when the permit is <br />Signature of Property Owner e"1". '{f ro tq <br />Print name of Owner lYlic tz (flr*./rnlqr'o <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 the <br />following person(s)to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description of Work)6a* (Ylater Rc lccse O uL.t <br />Project Location or Addressl lqll E.c+ lqth S{rcG+ - Suik A- Ssn{r Anc cA qa:los <br />Name of Authorized Agent:Amg\{otrtc ls - Sc,.r-{hcr <br />Address of Authorizeo agent: tZ}l{ Els* l?+h s'tre.. { 'SAolaAne CA 9a1ol <br />Phone Number of Authorized Agent r{tl('o- lSoS CcLl:.{q 35co18+ <br />I declare under penalty of perjury that I am the er for the address listed above and I personally filled out the above <br />.1lrr.ltq <br />Property Owner's Signature:Date <br />Print Name of Owner: <br />Note: A copy of the owner's driver's license, form notarizalion, or other verification ac to the agency is required to <br />be presented when the permit is issued to verify the propefty owner's signature. <br />P. i['r'.]p51,4)o!nierA.!rvity Assenbrle, slNo:i.e lo Properv I o:n 0,' 14 :l:.16 <br />SANTA ANA CITY COUNCIL <br />moulido@san1a-ana.oro <br />MlcheLe Msd.ez <br />fi,layor Pro Tem Ward 2 <br />miman nez@sante-ana oro <br />Vice.te Sam ento <br />vsarmiento@sants-ana,oro isolorlolosanta-6na.oro dbenavrdes@sanlr-ana.ora v I eoasrOsanta-ana,oro siinai6.o@santa-ana.oro <br />issued to verifu the Dropetfu owner's siqnature. <br />information and certify its accuracy. <br />foic.lrae \ tYl uqe,1 /-s^^ Aq{onlo S6r, Aera, LA