Laserfiche WebLink
[-l 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 Califomia Departmen: of Beneflt Payments, and the Califomia Division of lndustrial <br />Accidents. lalso understand lmaycontactthe Calirornia Contractors' State L:.ense Board (CSLB) at 1-800-321-CSLB (2752) or <br />wyyw.cslb.ca.oov for more information about licensed contractors. <br />10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party <br />legally a nanciall re spon lr ble for p posed onstruct activity at the followi ng 3add re <br />11. I agree that, as the party legally and flnancially responsible for this proposed construction activity, I will abide by all <br />applicable laws and requirements that govem Owner-Builders as well as employers. <br />-I4-r, 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 Contractors State License Board may be unable to assist you with any linancial loss you may sustain as a result of a com plaint. <br />Youronly 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 ofthat individual or flrm is injured while working on your property, you maybe held liable for damages. lfyou <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 />propedy 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. Nore; A coDv of the propertv owner's driver's license, form notarization, or other <br />verification acceptable to the aqency is required to be presented when the permit is issued to verify the propefty owner's <br />sionaturc. <br />Signature of Property Owne <br />Print name of Owner ./ <br />Date\ <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 rlle the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description of Work) <br />lz--- <br />-9.o 1K <br />DDAN \/ANI M IU T <br />Project Location or Address <br />Name of Authorized Agent: <br />Phone Number of Authorized Agent <br />I declare under penalty of perjury that I am lhe property owner for the address listed above and I personally filled 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 verification acceptable to the agency is required to <br />be presented when the permit is issued to verify the propedy owner's signature. <br />PL i'kl|t P:1 C'lu:ri.r:Aiii',1)'ASS,i ilr )Eills ll!lr:e lo Pr\ii,arir;o.m <br />SANTA ANA CITY COUNCIL <br />mouIdo@$.ta€na o.o <br />MBts Frc Td, Ward 2 <br />mrnadrnez@sa.la€na oro <br />V co.le Samrento <br />lsaimrento(DsanE-ana,orc sorono@sanlE ana oro <br />P Oavid Benavides <br />dbenavrdeslOsanla-ana oro vl6as6santa a^a mo slrnaE.o@sant -aoa do <br />^ <br />Address of Authorized Agent: