Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
r{lL g. f understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the <br />United States Small Business Administration, the California Department of Benefit Payments, and the California Division of lndustrial <br />Accidents. I also understand I may contact the California Contraclors' State License Board (CSLB) at 1-800-32'l-CSLB (2752) or <br />www.cslb.ca.qov for more information about licensed contractors. <br />-h4:[,le!ally an <br />address; <br />-UN,t , asree that, as rhe <br />a{plicable laws and requirem <br />I&2. t agree to notrry tne i <br />plbvided on this form. <br />I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I <br />d flnancially responsible for proposed on activity at t llowie <br />am the party <br />f>7bL <br />party legally and financially responsible for this proposed construction activity, I will abide by all <br />ents that govem Owner-Builders as well as employers. <br />ssuer of this form immediately of any additions, deletions, or changes to any of the information I have <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, <br />the Contractors' State License Board may be unable to assisl you with any financial loss you may sustain as a result of a complaint. <br />Your only remedy against unlicensed Contractors may be in civil court. lt is also important 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 damages. 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, this form must be completed and signed by the property owner and returned to the <br />agency responsible for issuing the permit, /Vole; A coov of the properlv owner's driver's license. form notarization. or other <br />verification acceDtable to the aaencv is reouired to be ted when the Dermil is issued to verifv the oroDertv owner's <br />sionature. <br />Signature of Property Owner Date: /['?7 <br />IPrint name of Owner <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) <br />Project Location or Address <br />Name of Authorized Agent <br />Address 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 Owner's Signature Date <br />Print Name of Owner <br />Note: A copy of the owner's driver's license, form notarization, or other veritication acceptable to lhe agency is required to <br />be presented when the permit is issued to verify the propefty owner's signature- <br />PL Lnk:r:,'P51 Cirr.rn:irAcilrilr Assanllll./3iiis flc,irce 1o Pr!i)cr:), Form <br />SANTA ANA CITY COUNCIL <br />mo![do@sa.ta'6na do <br />Mayor Pro Tem. Wad 2 <br />m,rurt n.!6 sanr.'ana o.o <br />Vce.le Samienlo <br />6ame.lo@sanl3 ana orc Edp!@$!.1a:!!!-e!9 dbenav,desosanla ana oro rM eoasasanla-ana oro sl nareroosa.la ana o.o