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///2" I understand I may obtain more information regarding my obligations as an "employer'from the lnternal Revenue Service, the <br />'u,/United States Small Business Administration, the Califomia Deoartrnenl of Benefit Pavments, and the Califomia Division of lndustrial <br />Accidents. I also understand I may contact the California Contractoristate Lrcense Board (CSLB) al 1-8OO-321-CSLB (2752) or <br />www.cslb.ca.qov for more information about licensed contractors. <br />I am aware of and consent to an Owner-Builder building pe rmit applied for in my name, and understand that I am the party <br />llv d nancially responsible for proposed construction activity at the foll ng <br />add ress -l-4 C <br />_'1 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all <br />applicable laws and requirements that govern Owner-Builders as well as employers. <br />_12. I agree to notify the issuer of this form immediately of any additions. deletions, or changes to any of the information I have <br />provided on this form. <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 Contraclors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a com plaint. <br />Your only remedy against unlicensed Contractors may be in civil court. lt is als o 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 damag es. 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 Iicensed and the status of their workers' compensalion insurance coverage. <br />Befor€ a building permit can bo issued, lhis form must be completed and signed by the prop€rty owner and returned to the <br />agency responsible for issuing the permit. ,Vore.' A cooy of the property owner's driver's license, form notarization. or other <br />,s dtobe senled when the I is ,ssued lo ve the e owner's <br />siqnature. <br />Signature of Property Owne Date -z ZL. <br />Print name of Owner ./t *L.,u LJq, [r <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property O\,,/ner, the execution of which I understand is my peBonal 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 />Name of Authorized Agent: <br />Phone Number of Authorized Agent <br />! declare under penalty of pe4ury that I am the property owner for the address listed above and I personally filled out the above <br />informatjon and certify its accuracy. <br />Property Owneas Sagnature Date <br />Print Name of Owner <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to lhe agency is required to <br />be presented when the permit is issued to verify tha propefty owner's signature. <br />PL nk.,i'P51 C!)r.i.rrAclr\ rly Assom5 yBrl s N(,irre li) Pr-a,i)aii!, Forri <br />SANTA ANA CITY COUNCIL <br />mpur,.loiosanla ana.o.o <br />Mayor Pro Tem Ward 2 <br />n,mn'nez6sa.la-a.a do <br />Mcste $m'ento <br />rmronroosanta-ana @ Edqr@$!l&a4e-ql9 <br />P D.v'd e€n6vd6s <br />dbenaud6@sanra-ana oro Mlleoas@sant3-ena ryo shnaEo@sa.la am do <br />7 <br />Project Location or Address: <br />Address ot Authorized Agent'