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H Ag. f understand I may obtain more information regarding my obligations as an "employel'from the lnternal n"r"nr" $. <br />vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Di'{- <br />sion of lndustrial Accidents. lalso understand lmay contact the California Contractors' State License Board (CSLIJ) at 1-800- <br />321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. <br />R h f O. 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 le <br />dress: <br />oa <br />1." <br />lly and flnancially responsib le for proposed construction a ctivity <br />^N <br />at the followin s ad-Oc\ €AsT cAtgT iJU T ,<7ALlf A A q z-'r c <br />H N f f . 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 />l,l h12. 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 someonewho does nothave 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 prope(y, 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 coov of the propertv owner's driver's license. form notariza- <br />to be reserted <br />Signature of Property Owner Date 3- tz- zoz o <br />Print name of Owner \-\rJN^(.FQ--i-O Ar,rar a ( <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)€?-ca'-r <br />Project Location or Address 6oq b . C!\gs-rt.tlUT <br />Name of Authorized Agent:+$A C\N \^ <br />Address of Authorized Agent:135 Do r)'rA t-^ A ((lrurn A,..t + <br />Phone Number of Authorized Agent lll ro-1 06:, q <br />I declare under penalty of perjury that I am the roperty owner for the address listed above and I personally filled out the above <br />information and certify its accu <br />Property Owner's Signature Date 3 lz-zoza <br />Print Name of Owner:A <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 ptesented when tha permit is issued to verify the property ownet's signature.