101102804 - Permit - Laserfiche WebLink

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Vg. lunoterstand I may obtain more information regarding my obligations as an "employei'from the lnternal Revenue Ser- vice, the Uniied 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.qov for more information about licensed contractors. H)rO I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following ad- dress: il$ f f . I 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. DhlZ. I agree to notify the issuer of this form immediately of any addltions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. lf you contract with 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 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. 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. Arofe: A copv of the propertv owner's driver's license, form notariza- tion, ot other verification acceDtable to the aqencv is requ ired to be oresented when the perrnit ,s ,ssued to verifv the propertv owne r's sionatu re. Signature of Property Ow ner Print name of Owner rl C< Excluding the Notice to Property Owner, the execution of whach 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 filled out the above information and certify its accuracy. Property Ownels 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 rssued to verify the property owner's signature. Date: AUTHORIZATION OF AGENT TO ACT ON PROPERW OWNER'S BEHALF zl *