715 N Lacy St Unit# C - Misc. Permit

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/1 .t YJlg. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Ser-' vice. the United States Small Business Administration, the California Department of Beneflt Payments, and the California Divi- sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Boaid (CSLB) at 1 -800- 321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the oartv leoallv and financiallv resDonsible for orooosed construction activitv at the followino ad-#;.',i7'"''"" 47;!:"' )i:'U A " ; f" r""d' ""';;l))r;" -'/i ii *b a. ?c rz, r '11. I agree that, as the party legally and flnancially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employersn- ffr L-lZ I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information IY have provided on this form. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the pe rmit. A/ote: A coDv of the DroDertv owner's driver's license. form notariza- tion. or other verification acceptable to the aoencv is required to be oresented when the permit is issued to verifv the property ow ne r's siq natu re. Signature of Property Owner Date /o-z o -2o/? Print name of Owner J; AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Name of Authorized Agent: Address of Authorized Agent Phone Number of Authorized Agent I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Property Owner's Signature Date Print Name of Owner Nota: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is re- quired to be presented when the permit is issued to verw the propefty owner's signature. Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Project Location or Address: