10193538 - Permit - Laserfiche WebLink

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.4N I t g. t understand lmay obtain more information regarding my obligations as an'employer" from the lnlernal Revenue Service, the Urlted States Small Business Administralion, the Califomia Department of Benefit Payments, and the California Division of lndustrial Accidents. lalso understand lmaycontactthe Calilornia Contraclors' State License Board (CSLB) at 1-800-321-CSLB (2752) or slb.c:,for more information about licensed contractors ally '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 aid financially responsible for proposed construction activity at the following address Y f f . I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all arplicable laws and requirements that govem Owner-Builders as well as employers. Mr., agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have ovided on this form. Licensed contractors are regulated by laws designed to protect the public. lfyou contract with someone who does not havea license. lhe 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 is also important for you to understand that if an unlicensed Contractor or employee of that individual or flrm is injured while working on your property, you may be held 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 the permit, /Vote.' A coDv of the ,roDeftv owner's d ver's license, form notarization. or other ted when rmil is issued to veri lhe owner's siqnature. Signature of Property Owner Date: /'0 /tt /2.a/ 7T77- Print name of Owner 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 prolect. Scope of Construction Project (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 filled out the above information and certify its accuracy. Property Owneas Signature Date Print Name oI Owner: Note: A copy of the owner's driver's license, form notarization, or other yerification acceptable to the agency is required to be presented when the permit is issued to verily the property owner's signature. SANTA ANA CITY COUNCIL moul'do@sa.ta-ana do llayor Pro Tem, Ward 2 m ma.!nez@sa.ta-.^a do V ce.le Samrenlo emâ‚¬.to@snta{na do Bolond@s3nla-ana do P Oavld Benavdes dbâ‚¬naedesdsanta-ana oro MlleoasAsanlr-ana oro st na'e.o@sanla..na oro l Address of Authorized Agent: