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V l{ <br />vice, the <br />sion of ln <br />321-CSL <br />I understand I may obtain more information regarding my obligations as an'employer" from the lnternal Revenue Ser- <br />United States Small Business Administration, the California Department of Benefit irayments, and the california Divi- <br />dushial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-g0O- <br />B (2752) or wu,rr. cs lb.ca.qov for more information about licensed contractors. <br />V-14 I am aware of and consent to an Owner-Builder building permit applied for in my name and understand that l?m the <br />ly and financially responsible for proposed construction activity at the following ad-party legal <br />d ress: <br />VJU l.agree that, as the party legally and fjnancially responsible for this proposed construction activity, I wilt abide by all <br />applic'able laws and requirements that govern Owner-Builders as well as employers. <br />\J--L1? I agree to notfy the issuer of this form immediately of any additions, deletions, or changes to any of the information Ir.lfavf/rovided on this form. <br />Ljcensed 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 court. lt is also important ior you to understand <br />that lf 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 wtlioe rispbnsiot6 for veifying <br />whether or not those Conlractors are properly licensed and the status of their workers' compensation insurance coverage. <br />Before a building permit can be issued, this form mu <br />to the agency responsible for issuing the permit, rr/o <br />st be completed and signed by the property owner and returned <br />te:A coDv of the Drooertv ow ner's driver's license. fo rm notariza- <br />tion or other table /s u e <br />\ignature of Property Owner Date: October 9,2019 <br />rint name of Owner Vicky Nguyen <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice <br />the following person( <br />Permit for my prolect <br />to Property Owner, the execution of whic <br />s) to act as rry agent(s) to apply for, sign, <br />h I unde my personal responsibility, I hereby authorize <br />ments necessary to obtain an Owner-Builderethe docu <br />Scope of Construction Project (or Descriptjon of Work) <br />Project Location or Address lVJ f,a/yut'e,q fuv dru/(,ame of Authorized Agent Thanh Hieu Nguyen <br />Address of Authorized Agent N CI o t/2 LA <br />0)0 / <br />Phone Number of Authorized Agent <br />I declare under penalty of perjury th <br />information and certify its accuracy. <br />at I am the property owner for the address listed above and I personally filled out the above <br />Print Name of Owner:Vicky Nguyen <br />Note: A coPy of the owner's driver's license, form notarization, or other veification acceptable to the agency is te-qulred to be ptesented when the permit is issued to verv the prope,ty ownels signature. <br />proDeftv owner's sidnatu re. <br />/)(./ <br />_) <br />(rrop"n, Ownels Signaturei Date October 9. 20]9