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9. I understand I may obtain more information regarding my obliglt ions as an "employer" from the lnternal Revenue Ser- ce.the United States Small Business Administration, the California Depa rtmerit of Benefit Payments, and the California Divi- sion of lndustrial Accidenls. I also understand I may contact the Calafornia Conlractors' State Llcense Board (CSLB) at 1 -800- - 3-21-CSLB (2752) or www cslb ca qov for more information about licensed contractors. 10. I am aware of and consent to an OwnerBuilder building permit applied for in my name, and understand that I am the party legally and financrelly rgi;ponsr!le for proposed construction achv(y at the following ad- dress \a\8 E,.\qL! \\. S.a*r* B^r. qa--ro\ 1 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all app licable laws and requiremenls that govern Owner-Builders as well as employers eg- have 12. I ayee to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I 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 financial 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 unhcensed 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. Betore 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. /Volei A copv of the properTy ownet's driver's license, form notariza- tion, or other verification acceptable to the aqencv is required to be presented when the permit is issued ,o verify the propedv owner's sionature.i\,o",",Q Izr lzozoSignature of Property Own I I Print name of Owner 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 responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file lhe documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work) Project Location or Address \3 \8 E r q\ 5\., 5o^\ Name of Authorized Agent R,\^'\s ov Ve6.nR,\o'k Address ol Authorized Agent \8c>--R.>..,-r""- \So*\- G.".r* 1\-ro\^ r\rq: -z\61 I declare under penalty of information and certify its Property Owneis Signatu perjury that I am the proggl{ own accuracf ) ', f/- . I \ er for the address listed above and I personally filled out the above \\zzlzozoDate,"/ Print Name of Owner E.ic\av\s 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 issued to verify the property owner's signature. Phone Number of Authorized Agent