2349 1%2 N Siemon St - Misc. Permit

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l4p I understand I may obtain more information regarding my obllgations as an "employe/'from the lnternal Revenue Ser- vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. lalso understand I may contact the California Contractors' State License Board (CSLB) at 1-800- 321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. lfuO.l am aware of and consent to an Owner-Builder building permit applaed for in my name, and understand that I am the party legally and fmancially responsible for proposed construction activity at the following ad- dress: z> Q.l '/z A/ . > tl/'4o z-. ,r -Wa I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. L*13. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this 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' State License Board may be unable to assist you with any flnancial 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 firm is injured while working on your property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and si ned the owner and returned to the agency responsible for issuing the permit. /Vofe.' tion, or other verification acceptable to the adencv is reauired to be presented when the permit is issued to verifv the proDeftv owner's sianature. Signature of Property Owner Print name of Owner Khtst)^Ja- /,q, -/ AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responslbility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my pro]ect. Scope of Construction Project (or Description of Work)9-oez rE ta-tilr* /lL,Qr a-a\ To k- tvabVcawt OF 4z/vto\bL <* kirUtz*-t rn.4t s. tb2At;^/c$ . LNoANj / rzaU @7z.stq,x1tj-C4r)e_ a-z//UZ. /\rzt* .-O//rJ^)t4 S /uU") Prolect Location or Addres Name of Authorized Agent: /\./ , 9 lE r,4O.-\/ D*/\/6 Z3YLl *NDW/ Address of Authorlzed Agent:5-7./ 2- A/CZ4!J Vt91-*btL /lovvi^Zzo,v ,%t*dl U 1?b?4 Phone Number of Authorized Agent 7/q -7Lq-O2-{ 6 I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Date: 1//o r/a/4 Print Name of Owner:k0-,<r )^to L,/ Note: A copy of the ownels driver's license, form notarization, or other verification acceptable to the agency is rc- quired to be prcsented when the permit is issued to verify the propefty owner's signature. Date:// ? "q Property Owner's Signature: