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2323 S Halladay St - Misc. Permit (2)
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2323 S Halladay St - Misc. Permit (2)
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Last modified
7/27/2021 11:34:23 AM
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7/27/2021 11:22:56 AM
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Misc. Permit
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2323 S Halladay St
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/. <br />,/ <br />-AA-9. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Ser- <br />./tl{e, the United States Small Business Adminishation, the California Department of Benefit Payments, and the California Divi- <br />sion oflndustrial Accidents. lalso understand lmay contact the California Contractors' State License Board (CSLB) at 1-800- , <br />321-CSLB (2752) or www.cslb.ca.oov for more information about licensed conlractors. <br />2AZ0 I am aware of and consent to an Owner-Builder buildang permit applied for in my name, and understand that I am the <br />pafl! legally and flnancially responsible for proposed construction activity at the following ad- <br />d rdss: <br />J4, I agree that, as the party legally and financially responsible for this proposed construction activity, I witt abide by atl <br />app[cable laws and requirements that govern Owner-Builders as well as employers. <br />.42.|agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />haye 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 flnancial 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 for you to understand <br />that if 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 will be responsible for verifying <br />whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. <br />plgpe rty owner's siqnatu re. <br />Signature of Property Owner Date 7 3a <br />a.-l-t uo =Print name of Owner <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 <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 pro.iect. <br />Scope of Construction Project (or Description of Work) <br />Project Location or Address <br />Name of Authorized Agent <br />Address of Authorized Agent: <br />Phone Number 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 /rcerrse, form notarization, or other verification acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the property owner's signature. <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 permit. l/ote-' A copv of the propeftv owner's diver's license. form notariza- <br />tion. or other verification acceptable to the adencv is reduired to be presented when the permit is issued to verifv the
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