10194524 - Permit - Laserfiche WebLink

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r{lL g. f understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of lndustrial Accidents. I also understand I may contact the California Contraclors' State License Board (CSLB) at 1-800-32'l-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. -h4:[,le!ally an address; -UN,t , asree that, as rhe a{plicable laws and requirem I&2. t agree to notrry tne i plbvided on this form. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I d flnancially responsible for proposed on activity at t llowie am the party f>7bL party legally and financially responsible for this proposed construction activity, I will abide by all ents that govem Owner-Builders as well as employers. ssuer of this form immediately of any additions, deletions, or changes to any of the information I have 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 assisl 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 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, /Vole; A coov of the properlv owner's driver's license. form notarization. or other verification acceDtable to the aaencv is reouired to be ted when the Dermil is issued to verifv the oroDertv owner's sionature. Signature of Property Owner Date: /['?7 IPrint 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 project. Scope of Construction Project (or Description of Work) Project Location or Address Name of Authorized Agent 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 veritication acceptable to lhe agency is required to be presented when the permit is issued to verify the propefty owner's signature- PL Lnk:r:,'P51 Cirr.rn:irAcilrilr Assanllll./3iiis flc,irce 1o Pr!i)cr:), Form SANTA ANA CITY COUNCIL mo![do@sa.ta'6na do Mayor Pro Tem. Wad 2 m,rurt n.!6 sanr.'ana o.o Vce.le Samienlo 6ame.lo@sanl3 ana orc Edp!@$!.1a:!!!-e!9 dbenav,desosanla ana oro rM eoasasanla-ana oro sl nareroosa.la ana o.o