10294915 - Permit - Laserfiche WebLink

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leqallv and financiallv responsible for proposed construction activitv at the followingaotriss: 2/7' 9'- Dar','t, 5ot^,/a, ,A-,n.r, Z t4 ?i> oZ' -7 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 lhat govern Owner-Builders as well as employers. llt Z. t agree to notify the issuer of this form immediately of any additions, deletions. or changes to any of the information 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 flnancial loss you may sustain as a result of a complaint. Youronly remedy against unlicensed Contractors may be in civil court. ltis also important for you to understand that if an unlicensed Contractor or employee ofthat individual orfirm is injured while working on your property, you maybeheld liable fordamages. 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 ths permit. /Vote: A copv of the Drooertv owner's driver's license. form notarization. or other verification acceotable to the aoencv is reouired to be Drese when the Dermil is issued to verifv the orooeftv owner's sionature- Signature of Property Print name of Owner Date )/1 AUTHORIZATION OF AGENT TO A CT 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 POect (or Description of Work) Project Location or Address Name 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 certify its accuracy. Property Owners Signature Date Print Name of Owner Note: A copy ot 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 propeny owner's signature. ] SANTA ANA CITY COUNCIL moulrdolasanla-Bna do Mayor P.o lem Ward 2 mrMnrnez@sanlE anE do Vicente Samrenro 6amrenro1osa.le{n3 do Eala!@$da:?.!a-o!s P Dav'd Benav,des dbenasdesaA$nt5.n3.do iu re5srAsants ana oro strn.Bo@sanla ana do I b_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 Benefit Payments, and the Califomia Division of lndustrial Accidents. lalso understand lmaycontactthe California Conlractors' Stale License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.oov for more information about licensed contractors. It A 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 Address of Authorized Agent: