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. ^ '\t/ <br />\l\e I understand I may obtain more information regarding 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 DivF <br />sion 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.oov for more information about licensed contractors. <br />_^p$" \tO. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />party <br />dress <br />legally n ncia ll y res S ro pos c str uAion activtA q"att following ad- <br />\a 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 />hav <br />12. I agree to notify the rssuer of this form immediately of any additions. deletrons, or changes to any of the information I <br />provlded 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 firm 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. l/ote.'A coDv of the DroDeftv owner's driver's license, form notariza- <br />tion, or other verification acceptable to the aqency is req uired to be Dresented when the Dermit is issued lo verifv the <br />proDertv owne r's sion atu re. <br />Srg nature of Property Owner Date \U <br />Print name of Owner <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execution of whach I understand is my personal responsibility, I hereby authorize <br />the following person(s) to act as my agent(s) to apply for, sign, and flle the documents necessary to obtain an Owner-Builder <br />Permit for my project. <br />Scope of Construction Project (or Description of Work) <br />Pro.lect Location or Address <br />Address of Authorized Agent <br />Phone Number of Authorized Agent: <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above <br />information and certify its accuracy. <br />Property Owneis Sagnature Date <br />Print Name of Owner: <br />Note: A copy ot the owner's driver's license, form notatization, or other verification acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify tho property owner's signature. <br />( <br />\ <br />Name of Authorized Agent: