Laserfiche WebLink
-fu , understand I may obtain more information regarding my obligations as an "employef'from the lnternal Revenue Ser- <br />.r/ice, tfD United States Small Business Administration, the California D?partment of Benefit Payments, and the California Divi- <br />'sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- <br />321-CSLB (2752) ot r,',r,',,r csi: :: rlf for more information abou[ licensed contractors. <br />-4 <br />. * lO. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />. dartv leqallv and financially responsible for proposed construction activity at the following ad- <br />i,"i'r,-BrZ W,l{Y\{ 5f. ,S"itE \oD inxirp. es@ <br />-,2 <br />{a't I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />-applicable laws and requirements tnat govern Owner-Builders as well as employers. <br />Z',, 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 havea <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 />a/-$eloie a building pormit can be issuod, this form must be complotod rnd signed by tho proporty ownor and returnod <br />. 1 \dthe agency responsibl€ for issuing the permit. ,Vofe: A coov of the propertv owner's driver's license. form notariza- <br />iion, or other verification acceotable to the aoencv is reouired to be prcsented when the Dermit is issued to verifu the <br />propertv owner's s i a n atu re. <br />Signature of Property Owner Date: G II Zo <br />Print name of Owner EfrlE>iD q / t7l7\.) w <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 icr my project. <br />Scope of Construction Project (or Description of Work)tJn rr{Ds CH I S <br />Proje ct Location or Address: 5\2 h]' l-fHST 9v o 5 A c-A. q2 Dtr, <br />Name of Authorized Agent:5.-,DDS. <br />Address of Authorized Agent:t v,l. t.1Td sr.Su E\9o 5 .i cA. qz-]oB <br />(r r'r) nBo - \6tsQ2 <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 Z_O <br />r ( tr.-, E >TD C.OL +r.r l.) <br />Note: A copy of the owner's driver's license, form notaization, 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 />Phone Number of Authorized Agent: <br />Print Name of Owner: