10294381 - Permit - Laserfiche WebLink

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W 9 I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the Uilt-ed States Small Business Administration, the Califomia Department of Benefit Payments, and the Califomia Division of lndustrial Actidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.aov for more information about licensed contractors. UL'IO.I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party I60ally and financially responsible for proposed construction activity at the following address: 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all a licable laws and requirements that govem Owner-Builders as well as employers 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have p vided 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 com plaint. Youronlyremedy 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 orUrm 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. ,Vore.'A coDv ol the DroDertu owner's license, form notarization, or other a to be senled when the rmit is issued lo the Signature of Property Owner n I Date Print name of Owner AUTHORIZATION OF AGENT TO AC T 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) 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 fllled 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 verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. SANTA ANA CITY COUNCIL mourdoaasanta .e oro MByot Pto 1e6. W ad 2 hfranrnâ‚¬z@sanle'ana do vEenle Samis.to v.sâ‚¬mâ‚¬nlo@sanIa-e.a oro Eoldo1e$nla-E.a oro P. Oav'd Bâ‚¬navrdes dben.sdesAsa.ta a.a.o.o v easasa.ta-a.a do sr .a e/c@sa.t. -a na oro sionature. '0, f ,', 7 Project Location or Address: Name of Authorized Agent: