20172895 - Permit - Laserfiche WebLink

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U,L 9. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue Ser- 'vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Divi- sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- 321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. l-' Z.to. I am aware of and consent to an Owner-Builder bu ilding permit applied for in my name, and understand that I am the party legally and fingncially Tgsponsible for proposed construction actiyity at throllowing ad- dress. )'//'t,,ir, ./(, /,'zt tl,( ',n., 7,t- ,/t,.r ,,. '/1,t, ,/ ULll .l agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all i-pplicable laws and requirements that govern Owner-Builders as well as employers. b'Lt.Iagreetonotifytheissuerofthisformimmediatelyofanyadditions,deletions,orchangestoanyoftheinformationI have provided on this form. Licensed contractors are regulated by laws designed to protect the public. lf you contract wath someone who does not have a license, the Contractors' State License Board may be unable to assist you with any flnancial loss you may sustain as a result of a complaint. Your only remedy against unlacensed Contractors may be in civil court. lt is also important for you to understand that af an unlicensed Contractor or employee of that individual or flrm is injured while working on your property. you may be held liable for damages. lf you obtain a permit as Owner-Builder and wash 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 pe rmit. /Vote: A copy of the property owner's driver's license, form notariza tion. or other verification acceptable to the adencv is reouired to be presented when the permit is issued to verifv the property ow ner's siqn atu re. Signature of Property Owner V / 14-41-'Y-zz,r{,7 ate O3^og ao2) Print name of owner .4-,r ln /z t,t t,-Trelt<Z- AUTHORIZATION OF AGENT TO ACT ON PROPERry 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 per1ury 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 verification acceptable to the agency is re- quired to be presented when the permit is issued to verify the property owner's signature. -:-.-