2125 N Arden St - Misc. Permit - Laserfiche WebLink

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I Att I-kl-g lunderstand I may obtain more information regarding my obligations as an "employe/ from tho lnternal Revenuo Ser- vice, the United Stales Small Business Administration, the Callfornia Department of Benefit Payments, and the Callfomia Divi- sion of lndustrial Accidents. I also understand I may contact the California Conhactors' State License Board (CSLB) at 1-B0o- 321-CSLB (2752) or www.cslb.ca.qov for more information about licensad contractors. 10. I am aware of and consent to an Owner-Builder building permit applied for in my namo, and understand that I am thepartyleoallv and.2-(-z = financially rosponsible for propos ed construction activ at the followin g ad-ity dress ,A*Z-EE{ =[.-5.-<r\t 11. I agree that, as the party legally and financially responsible for this proposed construction activity, lwill abide by all applicable laws and requirements that govern Owner-Builders as well as employers Ar -.J12. lagree to notlfy the issuer of this form immediately of any additions, deletions, or changes to any of the informalion I have provided on thls form. Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, the Contractors' Stato License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court, lt is also important for you to understand that if an unlicensed Contractor or employee of that individual or flrm is injursd while working on your property, you may be held liable for damages. lf you obtaln a permit as Owner-Builder and wlsh to hiro Contactors, you will be responsible for vaiifying whether or not thos6 Contractors are properly licensed and the status of their workers' compensation insurance covsrage. Bofore a bulldlng permit can bs is6ued, this form must bs complotod and slgned by the property owner and returned to the agoncy re6ponsiblo for issuin the pe rmit, tVofe; A coDv of ths Dropertv owner's drlver's license. fo notariza- o oroDerlv own er's siqnature Signature of Property Owner oate: 12 'o-2- ' | 1 Print name of own ", &4 r/ vLca AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notlce to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorjze the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obhin an Owrier-Bullder Permit for my prgect, Scope of Conskuction Project (or Descnption of Work)Oe- Proj ect Location or Add *"",424 AGzI:r! ->-r--g*r1A Atre,.)o Name of Authorized Agent: Address of Authorized Agent: Phone Number of Authorized Agent:1tA',t=4-'zbt, ldeclare under penalty of perjury I am the property owner for the ddress listed above and I personally lllled out he above information and certify its accu Property Owner's Sig nature l-'t *r* Date: ' r u/--rq \./ 1 Note: A copy ol the owner's drlver's llcense, form notarization, or othor verlficatlon accâ‚¬ptable to th6 agency ts re- quired to be presented when the permlt ls lssued to verlly the property owner's slgnature, Print Name of Owner: