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2109 N Pacific Ave - Misc. Permit
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2109 N Pacific Ave - Misc. Permit
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Last modified
7/27/2021 11:23:10 AM
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7/27/2021 11:22:44 AM
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Misc. Permit
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2109 N Pacific Ave
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JL 9. I understand I may obtain more information regarding my obligations as an "employel'from the lnternal Revenue Ser- <br />vice, the United States Small Business Adminiskation, the Cafifornih Department of Beneflt Payments, and the California Divi- <br />sion oflndustrial Accidents. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at1-800- <br />321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />tt <br />, I L 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />oartv leoallv and financiallv resDonsible for orooosed con'areis'4'l 01 N /),,'C. /4.,o' 9r,n-/,activitv.4 at the followi ng ad-q2 7D6 <br />J- p. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />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 have a <br />license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustaan as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand <br />that if an unlicensed Contractor or employee of that ind jvidual or firm is in.jured while working on your property, you may be held <br />liable for damages. lf you obtain a permit as Owner-Bu ilder 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 />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. Ivofe.' A copv of the propertv owner's driver's license, form notariza- <br />tion, or other verification acceptable to the aqencv is required to be presented when the permit is rssued to verifv the <br />property owner's siqnature <br />Signature of Property Owner <br />Scope of Construction Project (or Description of Work) <br />ProJect Location or Address <br />Be,r/ore l4^,'n Slaa/ lioz <br />Date il/zzlq <br />Print name of Owner <br />Excluding the Notice lo 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 file the documents necessary to obtain an Owner-Builder <br />Permit for my prolect. <br />I <br />Name of Authorized Agent: <br />Address of Authorized Agent: <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner: <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- <br />quired to be ptesented when the permit is issued to vefify the prcperty ownet's signature. <br />JL ,, .l agree that, as the party legally and financially 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 />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Phone Number of Authorized Agent:
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