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E-Bg , unuerstand I may obtain more information regarding my obligations as an "employei'from the lnternal Revenue Ser- <br />Jfce, the United States Small Business Administration, the California Department of Beneflt Payments, and the California Divi- <br />sion of lndustrial Accidents. lalso understand lmaycontactthe California Contractors' State License Board (CSLB) at1-800- <br />32'l -CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />B!<party le and fin ially res p9 nsible for pr o 's""s truction a vity the t.Ws^+r1 <br />dress r ,, \r4 <br />bg( I agree that, as the party legally and flnancially responsible for this proposed construction activity, lwill abide by all <br />hpplicable laws and requirements that govern Owner-Builders as well as employers. <br />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 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 />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. /Vote.' A copv of the propertv owner's driver's license. form notariza- <br />tion, or other verification acceotable to the aaencv is reduired to be presented when the permit is issued to verifv the <br />Drooeftv owner's sionature. <br />Signature of Property Owner Date ?3 .\ <br />Print name of Owner Vt,lv(7,(,4Wr "/l <br />AUTHORIZATION OF AGENT TO ACT ON PROPERry 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 />Permjt for my project. <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 fllled out the above <br />information and certify its accuracy. <br />Property Owner,s Signature Date <br />Print Name of Ownerl <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 presented when the permit is issued to verify the property owner's signature. <br />0. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />ScopeofConStructionProject(orDescriptionofWork):