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I understand I may obtain more information regarding my obligations as an .employef from the Internal Revenue Ser_ <br />United States Small Busin ess Administration, the California Department of Benefit Payments, and the Califomia Divi- <br />sion of lndustrial Accidents. I also undersland I may con tact the Califromia Contractors' State License Board (CSLB) at 1€OO- <br />321-CSLB (2752) or www.cslb.ca.oov for more informa tion about licensed contractors. <br />s{," <br />{,, <br />dress <br />I am aware of and consenl to an Owner-Builder build ing permitapplied for in my name, and understand that lam theparty legally and fina ncially responsible for pro posed construction activity at the follc'lvin ad- <br /><4.> <br />^J <br />1 1. I agree that, as the party legally and flnanciall y responsible for this proposed construction activity, I willabide by allappligDle laws <br />V ,r.,,n.. <br />and requkements that govern Owner-B uilders as well as employers <br />to notify the issuer of this form immediately of an y addilions, deletions, or changes to any of the information Ihave provided on this form <br />Before a building permit can be issued, thls form must bo com pleted and signed by the property owner and ret[medto lhe agency responsible for issui ng the permit. ,rrote..fotm <br />rs theDrope rtv own ef s s ionatu re. <br />Signature of Property Owner Date:AOJA <br />Print name of Owner il <br />Licensed. contractors are regulated by laws desig;ed to protect thB public. If you contract with someone who does not have alicense, the contractors' state License. Board m-y be unable to assist you wi[\ any financial loss you may sustain as a result ofa complaint.. Your only remedy against- unliconsed contracto,s may b" in ciril couit tt is also imfortant ior you to underslandthat F an unlicensed Contractor or employee ot that indivilual or firm is injured while working on jour froperiT, you may be heldliable for damages. lf you obtain a permii as Owner-Builder and wish to hire contactors, yo-u wirioe rispbnsioti ror veriryingwhether or not those contractors are properly licensod and the status of their wo*ers' cl'mpensation in|,run.. *r"rrg". <br />k <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Exd-uding the Notice to Propefi Owner, the execution of whictr I understand is my personal responsibility, I hereby authorizethe following person(s) to act as my agent(s) to apply for, sign, and file the documints necessary to ootain an oMler-BuilderPermit for my project. <br />Scope of Construction POect (or Oescription of Work) <br />Poect Location or Address 3S\3 3. Mbu"'>tr"<* <br />Name of Authorized eS".t, f Sg+eaiLrd <br />Address of Authorized Age nt, \5 <br />Phone Number of Authorized Agend lroA <br />I declare under penalty of perju <br />F te*tl-w ff\Rt fr6{ana-C^ q>:Sf <br />?D- <br />ry that I am the properv owner for the address listed above and I personally filled out the aboveinformation and cortify its accu <br />Property Owne/s Signature <br />Print Name of Owner h' K'ekt^^f,. <br />Dale: S 3 0eo <br />h <br />Note: A copy ol tlre a nar's driver's llcense, form notarizatlon, ot othet verirication accoptable to the agency ls re-quired to be preaented vhen the pqmft la lssuea to vitfy ii'pip"rry o*r"r,s signaturc.