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LMln tunderstand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Ser- <br />'vice, 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 />32'l-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />/4 r^-':' 10. 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 <br />d ress: <br />an ancial Iy s le pro sed co ction activity at the following ad- <br />llll!\ll.l 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 />h\1, 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 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' compensatron 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. /Vofe.' A copv of the propertv owner's driver's license. torm notariza- <br />tion <br />prooertv owner's sio natu re. <br />Signature of Property Owner Date ,ZO <br />Print name of Owner rt;,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 flle the documents necessary to obtain an Owner-Builder <br />Permit for my project. <br />Scope of Construction Project (or Description of Work) <br />Pro.ject Location or Address OgA 4orlUa- N,Ja- b\r/. Sutv- ?-ba 5p, Qffiol <br />Name of Authorized Agent oJ C--a'r[,.= t- <br />Address of Authorized Agent:9A? SaJt-o -Nap bl..od.6uir"- ?.:a SF qIZ?\ <br />Phone Number of Authorized Agent 2(O0x <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally fllled out the above <br />information and certify its accuracy.'7/l*''%o-- <br />Property Owneis Signature Date <br />j /ro/z,o <br />Print Name of Owner:tA"A k(,k,,; <br />Nota: 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 petmit is issued to ve fy the property owner's signature.