101106029 - Permit - Laserfiche WebLink

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c r 9. I understand I may obtain more rnformation regardrng my obftgalions as an "employer" from the lnternal Revenue Ser- vic., the Unrted Strtes Small Business Admrnrstration. the Californra Dep4.tmeIt gf Benefit Payments. and the Califomia DivF sioh of lndustrial Accidents. I also understand I may contact the Califomia Contractors' State License Board (CSLB) at 1-800- 321-CSLB (27s2)or www.cslb ca ov for more rnformatron about lcensed contractors E't-10. I am aware of and consent to an Owner-Burlder burldrng permrt apphed for rn my name. and understand that I am the party legally and financially responsible for proposed construction activity at the followrng ad- dress \:_l_1 1. I agree that, as the party legally and financrally responsrble for thrs proposed construction activity. I wrll abrde by all applicable laws and requrrements that govern O\uner-Builders as well as employers. f-\ Z f agree to notify the issuerotthis form rmmedrately of any additrons, deletions, or changes to any of the information I have provided on this form Ltcensed contractors are regulated by laws desrgned to protect the public. lf you contract wth someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may suslain 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 rndrvidual or firm is injured while working on your property. you may be held liable for damages, lf you obtain a permjt as OwnerBuilder 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. Botoro a building permit can be issuod, this form must be completed and signed by the property owner and returnod to the agoncy rasponsiblo for issuing the psrmit. /Vote; A coov of ahe prooetTv owner's driver's license. form notari2a- tion. or other verification acceptable to the aaencv is reouired to be prasented when the pamit is issued to verifv the proDedv owner's sionature. (Signature of Property Own '4 ^0",". \-LV -'z r /Pflnt name of Owner AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding lhe Notce to Property Owner, the executron of which I understand rs my personal responsibrlty, I hereby authonze the bllowing person(s) to act as my agent(s) to apply for. sign, and file the documents necessary to obtain an Owner-Bualder Permit for my project. Scope of Construction Project (or Des cnptr:;n olWoill.4ob.'(, r-!A+ 4e?-1, \. Project Location or Address Name of Authonze d Agent. \^t lla.L'f T>F+E >, Address ot Authorized Agent k-a L 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 cedity its accuracy {Property Ownels Sig 1->2 nalrJ--L ,trL () 9 )(-Date 1Zc-1 xPnnt Name of Owner.Z tr LL Note: A coPy ot the ownet's drivor's license, torm notarization, or othor vgrification acceptable to tha agency is re- quired to be prcsented whan the permit is issued to vetify the propefty owner's signature. Phone Number of Authonzed Agenr *l +f aa t - +t< c.l