Laserfiche WebLink
?1'1"/ g. I understand I may obtain more information regarding my obligalions as an "employel'from the lnternal Revenue SeI- <br />vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California DivF <br />sion of lndustrial Accidents. lalso understand I may contact the California Contractors' State License Board (CSLB) at 1-800- <br />321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />zry n.I am aware of and consent to an OwnerBuilder 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-'areis - izoz-uo+ i) Br.sr< qt. <br />fl'w-ll I agree that, as the party legally and flnancially 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 />Zlt'llZ. 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 impo(ant 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 slatus 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 copv of the propertv owner's driver's license. form notariza- <br />tion, or other verification acceptable to the adencv is required to be presented when the permit is issued to verifv the <br />Signature of Property Owner Date u [],+ l17 <br />A,,a U'-Print name of Owner <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 Conskuction Pro.iect (or Description of Work) <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 property owner for the address listed above and I personally filled out the above <br />information and certify its accuracy. <br />Property Ownef s Signature Date <br />Print Name of Owner: <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 verity the propetv owner's signature. <br />propertv owner's siqnature.