30138677 - Permit - Laserfiche WebLink

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-4,, I am aware of and consent to an Owner-Builder bullding permit applied for in my name, and understand that I am the party legally and frnancially responsible for proposed construction activity at the followingaddress: 4a Z ut ''t n srruzcr ''"'" -runderstand as an Owner-Builder if I sell the'property for which this permit is issued. I may be held liable for any financial or personal injuries sustained by any subsequent owhe(s) that result from any lalent construction defects in the workmanship or materials. -/9-' _9 I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the Unrted States Small Business Administration. the California Depanment of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contact lhe Californra Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.oov for more information about Iicensed contractors -4-9-- 11.1 agree that, as the party legally and financially responsible for this proposed construction activity. I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. -&r l 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. Lrcensed 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 complaint. 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 of that individual or firm is injured while working on your property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you wil be responsible for verifying whether or not those Contractors are properly Iicensed 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 theagency responsible for issuing the permit. A/ofe: A coDv ofthe Dropeftv owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permil is issued to verify the propedy owner's sianature. Signature of Property Owner Print name of Owner Date: i Zui -7 AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Properly Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to acl as my agent(s) to apply for, sign. and file the documents necessary to obtain an Owner-Buiider Permit for my project. LJ A'nlScope of Constructron Pro,ect (or Description of Work)A s l.) ,L 0 (e<-'^Y S Pro,ect Location or Address 4aLu.t 4fi srz<er Name of Authorized Agent:-7Wf Bepoo,.-.t Address of Authorized Agent:129 ut, Nt t-s(r\t 9lv--e I declare under penalty of perjury that I am the propâ‚¬rty owner for the address listed above and I personally filled out the above information and certify its accuracy Property Owner's Signature Print Name of Owner:lR -. a"', (),t'"-,rs,- Date: lO 2 'Zbl Note; A copy of the owner's drlver's licensa, form nolarization, or other yerlfication acceptable lo the agsncy is required to be presented when lhe permil is issued to verify the property owner's signaturc. SANTA ANA CITY COUNCIL t?16t, Pio 'Idr lryaro r vslmrlo6.rll.iâ‚¬ o.a Mm!cu.@sr. s^. @ P Oad B.ruuda DE&.$d6o.ar!tr-r.a orc ST'EcorOe.t 'an. oE 4'/<- RRe6r@sml..ena o.o Phone Number of Authorized Agent.