10192602 - Permit - Laserfiche WebLink

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Un d Sta understand I may obtain more informalion regarding my obligations as an "employer" from the lnternal Revenue Service, the tes Small Business Administration, the Califomia Department of Benefit Payments, and the Califomia Division of lndustrial Accidents. I also understand I may contacl the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or for more information about licensed contractors I am aware of and consent to an Owner-Builder building permit applied for in my name,du erstand that I am the party sible roand financially respon sed NS activity the fol ng address @,,,@)* provrded on gree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all ws and requirements that govem Owner-Builders as well as employers. ree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have this form. Licensed contractors are regulated by laws designed to protect the public. lfyou 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. Youronly remedy against unlicensed Contractors may be in civil court. lt isalso 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 damag es. 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 b6 issued, this form must be complâ‚¬ted and signed by the property owner and returned to the agency responsible for issuing the permit. Note; A copv of the propertv owner's driver's license, form notaization, or other verification acceDtable to the aqencv is required to be Dresen ted when the Dermil is issued fo verifv the oroDertv owner's siqnature. Signature of Property Owner Print name of Owner 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 file 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 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 filled out the above information and certify its accuracy. Property Owner's Signature Date Print Name of Owner: Note: A copy of the owner's driver's license, form notaization, or other verification acceptable to the agency is required to he presented when the permil is issued to verify the propefty owner's signature. PL in k:Vl P 5'1 i CounterAclivity.'Asse m b yBills, Notrce io Prope(y Fo.m SANTA ANA CITY COUNCIL rnD! do@santa-4na-ctaq Mayor fto Tem, Wad 2 mima.1 ne@sanla-anB oro vrcsnte Sam'enD Bamienlo@sanl!-an! oro P. Daud EenaMdes dbenasd6@sant.-ana oro MlleEs@sanla-ana oro stinale.o@sama-ena do A.4/7 AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF