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United States Small Business Administration, the California Departm.ent of Benefit Payments. and the Califomia 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.L legally L l understand I may obtain more information regarding my obligations as an employer'from the lnternal Revenue Service, the 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 p n ble for posed on ac at foll sa address 4) til, i-ppri* '1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all ble laws and requirements that govem Owner-Builders as well as employers. Ts?/:Z. , agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have rprovided on 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. 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 flrm 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 verirying 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. Nore A coDv of the DroDerty owner's driver's license, form notarization. or other verification acc to the /s n he il is issued ,o ve the o siqnature. Signature of Property Ow Print name of Owner Date /)- 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 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 notarization, or other verilication acceptable to the agency is required to be presented when the permit is,ssued to verify the propefty owner's signature. SANTA ANA CITY COUNCIL t moul'do@sanL-ane do Mayd Pro Tem. Ward 2 n'man,nezlosanE ana oro vi.srE s5mrsro !6amL6nto@sa.t3-ana oro Eefgllaletella:lli-gc dbe.aedesosa.la'anaorc r9l]!9!!@5a!E:r!!-e9 sll.arero@santa-an, oro + - 1 </1-