10193454 - Permit - Laserfiche WebLink

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E-).- d. I g. t 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 Benefit Payments, and the Califomia Division of lndustrial Accidents. I also undersland 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.4 '10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally an address: d fina c !lv resoonsibz- s.le for proposed co stru ron at th followin s ,Z -/ 1l.lagree that, as the party legally and rinancially responsible for this proposed construction activity, lwill abidebyall aO-plicable laws and requirements that govern Owner-Builders as well as employers. -.(1)2. t agree to notify the issuer of this form immediately of any additions. deletions, or changes to any of the informalion 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 com plaint. 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 ofthat individual or firm isinjured while working on your property, you maybeheld liable fordamages. 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 bo issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. ^rofe: A copv of the oropeftv owner's driver's license. lorm notarization. or other verificalion acceptable to the y is required to be Dresented when lhe permit is issued to verifv the DroDertv owner's 9!Snature. Signature of Property Owner -2- Z-d Y- <\ -c-{.\a_9_j-1 Date 7rl2. \Q Print name of Owner AUTHORIZATION OF AGENT TO AC T 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 project. Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent Address of Authorized Agent I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Property Owner's Signature Date 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 verily the property owner's signature. SANTA ANA CITY COUNCIL moul'do@sanla-a.a.oro Illat$r Pro Tem. Ward 2 mrman ne2@sanla'ana oro Vrcenle Samiento Bamrnlorasanta ana do 60rono@s.nta-ana oro P. Daed Bâ‚¬naMdes ,.os!!vlc!!@!rd!=l!!.![g rs eoasAsanla-ana orc snnaâ‚¬rd@sanL-ane do Phone Number of Authorized Agent: Print Name of Owner: