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.l, <br />-{&. , understand I may oblain more information regarding my obligations as an "employer" lrom the lnternal Revenue Service, the <br />[.lDited States Small Business Administration, the Califomia Department of Benefil Payments, and the Califomia Division of lndustrial <br />Alcidents. I also understand I may contact the California Contractols' State License Board (CSLB) at 'l -800-321-CSLB (2752) or <br />cslb.ca for more information about licensed contractors <br />'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 <br />llyrfd financially responsible for proposed construction activity at the following <br />re 2 <br />11. I agree that, as the pa(y legally and llnancially responsible for this proposed construction activity, I will abide by all <br />licable laws and requirements thal govem Owner-Builders as well as employers <br />2. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />vided on this form <br />Licensed contractors are regulated by laws designed to protect the public. lfyou contract with someone who does not have a licens€, <br />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. <br />Your only remedy against unlicensed Contractors may be in civil court. lt is also imporlant for you to understand that if an unlicensed <br />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 <br />obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying whether or not those Contractors are <br />properly licensed and the status of their workers' compensation insurance coverage. <br />Before a building permit can be issued,is form must be completed and signed by the property owner and returned to the <br />agency responsible for issuing the pe t.Nole: <br />siqnature. <br />Signature of Property Owner' <br />Print name of Owner <br />v <br />rrj.".,o{Lo.r; e <br />Dale: /t -ltl-2Li2 <br />,VZJ <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the <br />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 <br />project. <br />Scope of Construction Project (or Description of Work)ll-.-{ <br />Project Location or Address 55 l, - lc <br />Name of Authorized Agent: <br />Phone Number of Authorized Agent: <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally fllled out the above <br />information and certify its accuracy. <br />Property Owneis Signature <br />Print Name of Owner <br />Note: A copy of the owner's driyer's license, form notarization, or other verification acceptable to the agency is requircd to <br />be presented when lhe permit is issued to verify the property owner's signature, <br />?L.li !r!'F5i C.,rri.rrActi\rll AsS.rrr,Sr!B lS l^.1.,1!!e lo Prlri)ei! Form <br />SANTA ANA CITY COUNCIL <br />mbul doi@sanl3-ana oro <br />Mayor Pro lem WErd 2 <br />mr@n ne!(!$nla-a.a oro <br />Vrceni€ Sa@enro <br />63m'enro@s3nta a.e o.d Lsdono@sanla-ana oro <br />P Oav'd A€n.vidn <br />dbeneudes@santa-ane oro relleoaslosan|a-an3.oro srrntsErolosenlg-ana.oro <br />, <br />Address of Authorized Agent; <br />Date: