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101106116 - Permit
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101106116 - Permit
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Last modified
9/9/2021 8:01:59 AM
Creation date
9/8/2021 5:06:15 PM
Metadata
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Template:
Permit
Permit Number
101106116
Full Address
4713 W Henderson Pl
Permit ID
273237
Master ID Number
2021-164842
Project Name
Le Residence Window Changeout
Street Number
004713
Street Direction
W
Street Name
Henderson
Street Suffix
Pl
Building Use Code
Resid-1 unit
Job Types
Alteration
Permit Type
Building
Applied Date
3/12/2021
Issued Date
3/12/2021
Finalized Date
3/16/2021
Flood Zone
A-0602320256J
Description of Work
Legalize windows changed out.
Nature of Work
Windows
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$---g. t 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 Benefit Payments, and the California Divi- <br />sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- <br />321-CSLB (27521 or www.cslb.ca.qov for more information about licensed contractors <br />ttL-10. 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 legally and financially responsible for proposed construction activity at the following ad- <br />dress: <br />t1L- f .l 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 govern Owner-Builders as well as employers. <br />#lrn.l 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 rs 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 pe rmit. /Voter A copv of the Dropeftv owner's driver's license, form notariza- <br />Signature of Property Owner Date l)Ll <br />Print name of Owner -XrAt\I+LE- <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 following 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 ption of Work) <br />Project Location or Address <br />Address of Authorized e nt; <br />Phone Number of Au orized Agent <br />I declare under <br />information and <br />alty of perjury that I am the pro and I personally filled out the above <br />rtify its accuracy <br />Property ner 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 re- <br />quired to be presented when the permit is issued to verify the property owner's signature. <br />owner for the address listed a <br />Drooeftv owner's siqnature.A <br />Name of Authorized Agent:
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