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g. I unOerstanO I may obtain more information reglrOing fly obligations as an "employef'from the lnternal Revenue Ser- <br />vtce,the United States Small Business Administration, the California Department 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) or for more information about licensed contractors. <br />\-\I <br />'V'lY IO. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />party legally and financially responsible for proposed construction activity at the following ad- <br />dless: <br />tU1I t t <br />1 1 . 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 that govern Owner-Builders as well as employers. <br />AA <br />\NU12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />llave provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract wilh 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 />re a building permit can be issued, this form must be completed and signed by the property owner and returned <br />the agency responsible for issuing the pe rmit. ,Vote.' Leopy of the property owner's driver's license, form notariza- <br />on or be nted when the rmit is issued to the <br />proDertv owne r's siqn atu re. <br />nature of Property Owner 0,;4 Date tL 3 <br />rint name of Owner * u\trorr 0 e.H5 Ulx) <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 project. <br />Scope of Construction Project (or Description of Work) <br />Prqect Location or Address & SATJTA 16- =T &a A,s 1>toi <br />+tanti;6fXitllDrizeo esEn ,,llk{?^ t o ?enrfu,l <br />Address of Authorized Agent 6){ S'o, SnnrTA (e sr Sn/r7A ApA QazoE- <br />Phone Number of Authorized Agent (Qt/a ) 3tr'l )t q 2.- <br />I declare under penalty of perjury that I am the property owner the <br />(^ <br />listed above and I personally filled out the above <br />information and certify its accuracy/ <br />Property Owner's Sagnature 3 IrqDate <br />Print Name of Owner:*n o1 l-t't-)TCtil <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 propetv owner's signature.