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f I L l understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Ser- <br />vice, the United States Small Busjness Administration, the California Department of Beneflt Payments, and the California Divi- <br />sion of lndustrjal Accjdents. 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 />tS tO. 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 responsibl e for pro sed construction activity at the following ad- <br />d ress <br /><< 11.1 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 /><S 12.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 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 />Before a building permit can be issued, this form must be completed and signed by the p.operty owner and returned <br />to the agency responsible for issuing the permit. ,Vote.' A copv of the propertv owner's driver's license, torm notariza- <br />tion. or other verification acceptable to the aoencv is reouired to be presented when the permit is issued to verifv the <br />proDertv owner's sid natu re. <br />Signature of Property Owner B Date u /8lt 1 <br />print name of owner SHe SHa SUREEN <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <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 prope(y 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 <br />Print Name of Owner: <br />Note: A copy of the owner's driver's ,icensg form notarization, or other ve fication acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the property owner's signature. <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 />ScopeofConstructionProject(orDeScriptionofWork):