10293699 - Permit - Laserfiche WebLink

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t t.{ ff_Lg. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the' Unlted States Small Business Administration, the Califomia Department of Benefit Payments, and the Califomia Division of lndustrial Accidents. I also understand I may contact the Calilornia Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.oov for more information about licensed contractors. tt1- fi_L10.1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party 'legally and financially responsible for proposed construction activity at the following address:ffi #lp ffiIio"o . I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all le laws and requirements that govem Owner-Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have on this form. Licensed contractors are regulated by laws designed to protect the public. lfyou contract with someone who does not havea license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a com plaint. Youronly remedy against unlicensed Contractors may be in civil cou(. lt is also important for you to undersland that if an unlicensed Contractor or employee of that individual or firm is injured while wofting 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 permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. ,Voae. A copv of the propertv owner's driver's license. form notarization. or other verificalion acce able to lhe rs re uired to be nted when the rmit is issued to ve the o er's siqnature. Signature of Property Owner Date ?/z/ / 7 Print name of Owner 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 flle the documents necessary to obtain an Owner-Builder Permit for my Scope of struction Proiect(or p PLin k:W P51 ption of Work) Project Location Address Name of Authorized nt: Address of Authorized Age Phone Number of Authoriz Ag I declare under penalty perjury that I a ounterActivitylxssemblyBillslNotic informaten and Property Oilrngr accuracy 's Si ature Note: A copy the owner's driver's ,icense, be presented en the permit is issued to r the address listed abovc and I personzllly lllled out the above Date: ble to lhe agency is required lo SANTA ANA CITY UNCIL e o Property Fonri property owner tion, or other verification ac wner's signature. Itcâ‚¬nre S6n'enro #mrdlo@sant!'ane m P Oaud B6naedes dbâ‚¬na$d6@samr-3n, nd sr'naao@srnll-ana do <t' Print Name of Owler: .r*" s/* oDrâ‚¬--tso'Mgasan', ana &