102103580 - Permit - Laserfiche WebLink

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B-g. I understand I may obtain more information regarding my obligations as an "employer'' from the lnternal Reveirue Ser- vice, the United States Small Business Administration, the California Department of Benefit Payments, and the California DivF 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.oov. for more information about licensed contractors. A 4 f O. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the !:gl"$trrrrTrS9llv4";co,''l'iole for proposed construction activitv at the followins ad- A ,1 ll.l agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. W12.1agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. 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 permit. ivote.' A copv of the D.rooaftv ownar's drivefs licensa, form notariza- tion. or other veritication acceptable to the aoencv is reouired to be presented when the permit is issued to verifv the owner's si neture.e agnature of Property Owner l1 l, i 1 f),.,e Date /'7 202o L Print name of Owner Scope of Construction Project (or Description of Work) flL IU N AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibilaty, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and flle the documents necessary to obtain an Owner-Builder Permit for my project. D tnuLL ;:, n pet n c7, ct' o/ rr, (t {n h'c,, Proj ectLocationorAddress: 502L LU </AsL N.r+rbr.ilc:Lin., B J+,t-taAnct^ CALI)toe Name of Authorized Ag -) ent, .THOi J-HANH VO nHIS AS.5/GNEF- Address of Authorized Ag ent:{D26 tr/<7hsL Sct,'in Anc,(-t1 427 b1 Phone Number of Authorized Agent:'7/tl- 7ZC- Oi ) 1 ?L 7/ t1 -fiz. 2oO/ I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accurac \ 1 I6Property Owner's Signature Print Name of Owner: ,l H THI H\-' Dale O z A/ Note: A copy of the owner's driver's llcense, 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. Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a license, the Conkactors' 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 unlicensed Contractors may be in civil court. lt is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish 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. 1 t'l LOt