10193340 - Permit - Laserfiche WebLink

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4A I understand as an Owner-Builder if I sell the property for which this permit is issued. I may be held liable for any finarrcial or personal iniuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. tâ‚¬n I understand I may obtain more information regarding my obligations as an'employer'' from the lntemal Revenue Service, the United States Small Business Administration. the California Department of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. '/Q- rc I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party addressl leoallv and financiallv res- 4o'1 (,\J qr\ponsible for proposed construction activity at the following 5 rvzeS tA, &, I agree that. as the party legally and financially responsible for this proposed construction activity. I will abide by all applicable laws and requirements that govern Owner-Buiiders as well as employers. 4, I agree to notffy the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. 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. Before a building psrmit can be issued, this form must be completod and signed by the property owner and returned to the agency responsible for issuing the permit. /Vote:coov of the Drooedv owner's driver's license form notarization, or other verification acceptable to the aoencv is reouired to be Dresented when the Dermit is issued to veri fu the Drooertv owner's sionature. Signature of Properly Owner Print name of Owner Date Z<;t') (La.* 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 tollowrng person(s) to act as my agent(s) to apply for, srgn, and file the documents necessary to obtain an Owner-Builder Permit for my proJect. Scope of Construction Project (or Description of Work)(Z< ^arr-r.- r)ftsevr<-xrf ftfd AL ctf6r a= Proiect Location or Address c{o'l w.4^ +b Name of Authorized Agent :.I})rf BeYOo,l Addrsss of Authorized Agent lL9 u. tltLrr^f 9f +tbc) <b4 mia\.G) gZaZ-\ Phone Number of Authorized Agent 1'(1 122'71{u) I declare under penalty of periury that I am the property owner for the address listed above and I personally fillsd out the above information and certify its accuracy Property Owner's Signature Date .zd / 'l \Q-nr* C/,r",'-rc--Print Name of Owner: Note: A copy of lhe owner's driver's license, form notarization, or olher verification acceplable to the agency is required ao be presented when lhe permit is issued to verify the property owner's signature. SANTA ANA CITY COUNCIL Mncern F Srrlcik M.yo Pro lfi W..d j Vs.frsllo6sel'-s. 0.6 Mlbn'n.zrasla s. d. AAftzclaJaenla ani m O8en.yld6osnG-aa r..RR.6!O3rn -,E do -rztL-