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101104242 - Permit
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101104242 - Permit
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Last modified
9/9/2021 7:43:03 AM
Creation date
9/8/2021 5:05:25 PM
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Permit
Permit Number
101104242
Full Address
2530 N Grand Ave
Permit ID
267192
Master ID Number
2020-160596
Project Name
Rear Yard Gate
Street Number
002530
Street Direction
N
Street Name
Grand
Street Suffix
Ave
Building Use Code
Office
Job Types
Parking Lots
Permit Type
Building
Applied Date
8/5/2020
Issued Date
1/28/2021
Finalized Date
3/10/2021
Flood Zone
X-0602320163J
Description of Work
Re-striping of two existing accessible stalls.
Nature of Work
Re-stripe
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h.? e. t understand I may obtaan more information regardang my obligations as an "employer" from the lnternal Revenue Ser- <br />vice, the United States Small Business Administration, the California Department of Beneflt Payments, and the California Divi- <br />saon of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800- <br />321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />t{./<o I am aware of and consent to an owner-Builder build <br />and flnancially re sible for propos ed constructiS <br />ing permit applied for in my name, and understand that I am the <br />on activity at the following ad-party legally <br />dress: Z 3 <br />H,% ll.l agree that, as the party legally and financially responsrble for this proposed construction activity, I will abide by all <br />applicable laws and requirements that govern Owner-Builders as well as employers. <br />1"4'? lZ. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I <br />have 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 <br />license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand <br />that if an unlicensed Contractor or employee of that individual or flrm is injured while working on your property, you may be held <br />liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not those Contractors are properly 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 <br />to the agency responsible for issuing the permit. /Vote: A coov of the orooertv owner's driver's license. form notariza- <br />tion, or other verification acceptable to the aqency is required to be presented when the permit is issued to verify the <br />Signature of Property Owner Date <br />Print name of Owner 2 €,/4,/ <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 <br />the followlng person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder <br />Permit for my project. <br />Scope of Construction ProJect (or Description of Work) <br />Project Location or Address <br />Name of Authorized Agent <br />Address of Authorized Agent <br />I declare under penalty of perjury that I am the prope(y 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 verilication acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the property owner's signature. <br />p roDertv ow ne r's s i q n atu re.,h*, <br />Phone Number of Authorized Agent:
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