Laserfiche WebLink
#;,;. ,";.] <br />I understand I may obtain more information regardirig my obligations as an 'employef from the lntsmal Revenue Ser- <br />United States Small Busirress Adminisiration, the Califomia Department of Benefrt Payments, and lhe Califomia Divi- <br />sion of lndustrial Accidents. I also understaod I may conlad the Califomia ContracloB' Slate Licens6 Board (CSIB) at 1-800- <br />321-CSLB (2752) or www.cslb.ca.ooy for nlore inloim.ation about licensed contraclors. <br />10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand lhat I am lhe <br />pa and :*7fl!ible for <br />5/t t n pfo construct at following ad- <br />dress Z 4 2aA <br />t'-A't't.l agree that, as lhe psrty legally and financially responsibls for th6 proposed construclion acdivity, I will abile by all <br />-appliteble lav/s end requiremenls lnal govem Owner-Builders as well as employers. <br />{Q,r.l agree to notiry the issuer of this form immediately of any additions, deletions, or changes lo any of the information I <br />have proviled on this form. <br />Licensed cootraciors are regulated by laws desoned to pmtect the public. lf you cor rac{ with someone who does nol have a <br />license, the Contraclors' State License Board may be unable to assist you wilh any financial loss you may sustain as a result of <br />a complainl. Your only remedy againsl unlicensed Conlraclors may be in civil court. lt is also important for you to understand <br />thal if an unlicensed Conlrador or employee ofthat indMdual or firm is injured while working on your property, you may be held <br />liable for damages. lf you obtain a permit es Owner-Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not those Contraclors are pmperly licensed and the slatus of their workers' compensation insurance coverage. <br />Before a building p€rmit can be issued, this form must be completed and signed by the property owner and retumed <br />totheagencyresponsiblefo]issuingthepermit.Note: <br />lion. o( dher verilication acco,,,bte to the aoencv ls reault!"d to be oresented when the ,€rmit is issued to verifv the <br />prooerlY owner's s io natu re, <br />Signature of Property Owner <br />Print name of olflner t/ <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Prop€rty Oflner, 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 file the documenls necessary to obtain en Owner-Builder <br />Permit for my proiecl. <br />Scope of Construclion Projed (or Oescription of Work) <br />Poecl Location or Addr€ss <br />Name of Aulhorized Agenl <br />Phone Number of Aulhorized Agent: <br />I declare under ponalty of perjury that I 8m the property owner for the address listed above and I p€rsonally filled out the above <br />inbrmation and ce ify its accuracy. <br />Property Owner's Signature:Oate: <br />Print Name of Owner: <br />Note: A copy d tthe o,,,nefs ckivels tlcense, fon noartzadon, or d,her wriftcatlon accefubte to the agency is re- <br />quirect to be presentec, when the permit is issued to verify tlrc property a nefs slgnature. <br />aa": .)5-eo- AO <br />Address of Authorized Agenl: