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CITY OF SANTA ANA <br />Planning if* and Building Agency I <br />If <br />V9. 1 undemtanoJ I <br />�, me unfttq\i Ststes Small <br />Mon ot hildust�el Accydents. <br />321,mC-SLB (2752) or <br />may obtain more infomiaUon mgarding my oblIgations as nn'oemployer* fir �n I.tc�° `' =: �' `• <br />Business AdmInIstration, the Califomin Department of Lienein Paymef t 10 ��0 �rC�'ved <br />,w, - e <br />rr <br />also understandi may contact the Celffomle Contractors' state LICAt '�'OR'PPP1kA1T iqq"Ar\ir�- <br />Iv for more Infortnatlon about Ilcensed contactors. <br />10. I ern aware of and consent to an Owner -Builder building permit applied (or In my name <br />Party k�pally and finanaally responsible for proposed construction activity at the following ad- <br />drP�c, <br />L11.1 ague that, as the party legally and financially responsible for this proposed construct <br />►aws and repuirements that govern Owner -Builders as well as employers. <br />2I agree to notify the issuer of t <br />have provided on this fo <br />rvn <br />d iindt`�J�� <br />., <br />., <br />0 <br />Master ID:' HE GOLDEN CITY <br />4111b.— FOUNDED 1869 � <br />Date: <br />ion activity, I will abide by all <br />his forth immediately of any additions, deletions, or changes to any of the information <br />Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a <br />litense.theContractors' State License Board maybe unable to assist youwith anyfinancial loss you maysustain as a result of <br />a complaint. Your only remedy against unlicensed Contractor's may be in civil court. It is also important for you to understand <br />that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held <br />Liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not thane Contractors are properly licensed and the status of their workers' compensation insurance coverage. <br />fore a building permit can be issued, this form must be completed and signed by the property owne <br />to the agency responsible for i <br />a other ve�cation accei <br />arvpe�ty owner's sivnature. <br />ssuing the permit. Note: A cg2jti <br />ble to the aaencv is required to <br />Signature of Property Owner I Date: <br />Prkd name of Owner Dennox Management LLC/ Shideh Dinani (Manager) <br />r and returned <br />s frwrm »nt=ri7a_ <br />,.1 ,, �• . - <br />f 3t�LbG� <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />F=b <br />Og the Notice to Property Owner, the execution of which I understand is my personal responsibility, Thereby authorize <br />the fobywing person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder <br />Pe for my project. <br />Scope of Construction Project (or Description of Work): C (..-- ka« <br />Project Lomion0 <br />or Address: 61o5 swy`\ k �"v`%c�' <br />Niame of Authodced Agent.* ck,\i <br />,�huthorized Agent.,�-�-� l�,c'�c.lc qZ0S3 <br />?hone Number of Authorized Agent,* � I (� 3L � (0 `lob 3lo Zco P '71)L <br />I dedare. under penaNy of pedury that I am th <br />k*mwr.,on and certify b accuracy. <br />pr(>ptaytj,inees Signal ut(...0 <br />PrVs Harno of Owner.. <br />perty owner for tho address listed above and I personally filled out the above <br />11 <br />— Date` <br />S i &JW <br />C "ON L5 <br />�-% I I (ONO <br />Ak*sfo A � opy rg the ownorOx drIvejOS 11conso, form notedration, or other veriftation accopublo to the .yviic y is rv- <br />grnlnd a, tpe pr"*nW when tl►e pormft II 18sued to vorily the luoportv ownerts signature. <br />