10294188 - Permit - Laserfiche WebLink

Home Browse Search

r!\''^ 9. I undersland I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the Califomia Department of Benellt Payments, and the Califomia Division of lndustrial Accidents. Ialso understand Imay 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. ,\i* 10.l 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 resronsible for propgsed address: f i, i \ L, rL \^ \, ) r,.-- con G slruction activitv at the followind^^. (; 9Lzt I I l' ).- 1'1. 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-Builders as well as employers. +rl'12.Iagreetonotifytheissuerofthisformimmediatelyofanyadditions,deletions,orchangesloanyoftheinformationIhave provided on this form. Licensed contractors are regulated by laws designed to protect the public. lfyou contract with someone who does nothave a license, the Contraclors' State License Board may be unable to assist you with any linancial loss you may sustain as a result of a com plaint. Youronly remedy against unlicensed Contractors may be in civil courl. lt isalso important for you to understand that if an unlicensed Contraclor or employee ofthat individual or firm is injured while working on your property. you may be held liable for damag es. lfyou 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 pe.mit.Note: A copv of the propedy 9y4er's driverb license, form notarization, or other verificalion acceDtable to the aoencv is reouired to be orese when the permit is issued to verifu the oroDertv owner's sionature. I ltrlrSignature of Property Owner Date Print name of owner ,!l I tlTJ l),,,r4r;h,r1ta :1 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 prolect. Project Location or Address 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 fllled out the above information and certity its accuracy Properly Owner's Signature Date: (Ir,lt I Print Nameof Owner' ,",\ r(.-.i "l nrlt\,,',(t Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature, SANTA ANA CITY COUNClL mou do@sanla-an3.qo l,layo. Pro Tem, Wad 2 m marllne2@santa'ana oro E9&!9@sE!h:@r.!a P Oavid Benavldes dbenaMdes@sa.ta-.na o.o iylleoas@ssnlts-ana oro sl'naE.olAsaota'en. orolsarm e.toaAsanta a.a oro ScopeofconstructionProJect(orDeScriptionofWork);