10194242 - Permit - Laserfiche WebLink

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I f1r. t understand I may obtain more information regarding my obligalions as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of Benelit Payments, and the California Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-32'1-CSLB (2752) or www.cslb.ca.oov for more information about licensed contractors. J-&'tO.l am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party , ::::,:,:^,'p2rw ",g w 3g s*"9fl*,qa")y .))f f;b*'f ,e 2 z 7a 7 Jafn't.tagree that, as the party legally and financially responsible for this proposed construction activity, lwill abide by all applicable laws and requirements that govem Owner-Builders as well as employers. JL4'z I 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 lo assist you with any financial loss you may sustain as a result of a com plaint. Youronlyremedy against unlicensed Contractors may be in civil court. lt isalso important for you to understand that if an unlicensed Contractor or employee of that individual or llrm 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 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. A,lote.' A copv of the propertv owner's driver's license, f orm notarization. or other yerification acceptable to the aaency is required to be presented when the permit is issued to verify the property owner's sidnature, ru/< z,/x"zzSignature of Property Owner Date Print name of Owner Ju I nil *t uioZ AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF project ,4JScope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent; Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally fll d out the above information and certify its accuracy oare: /d Z dProperty Owneis Signature Ju /.'t/z/,z/ct,Za Z 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- PL rk .:t'P5l Ccu.::.Aa:ii,.,ily'Assemblf 3 ls.Niiiae tc P:ipartl Fo.n SANTA ANA CITY COUNCIL 4P!lr.0.s@$-Eâ‚¬:!-03. Mayor Pro Tem, Ward 2 mrman'nez@santa anaoro Vicenie Sarmlento vsa.mrenlo@sanla ana.oro Eplplp@s4Eia@ilq P Da! d Benavides !-b.e!!!r.d.c9@sE!.8:!.!3.9ls rv eoas@sanla ana oro 9!!et9l9@s3!1ej3!3!Ig 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 Phone Number of Authorized Agent: _ Print Name of Owner: