20171261 - Permit - Laserfiche WebLink

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I understand I may obtain more inbrmation regarding my obligations as an "employef'from the lntemal Revenue Ser- the United States Small Business Administration, the Calibmia Department of Benefit Payments, and the California Divi- of lndustrial Accidents. I also understand I may contact the Califiornia Contractorc' State License Board (CSLB) at 1-800- 321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the for at 1z t)l'n,l/v2 NAo /^i / N )11. I agree that, as the party legally and financially responsible for this proposed construction activity, t will abide by all hfpfrcable laws and requirements that govern Owner-Builders as well as employers. 12. I agree 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 br 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 br 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 oovemge. Before a building permit can be issued, this form must bc completed and signed by tha proporty owner and returncd to the agency rcsponsible for issuing the permit. Note: A coov of the orooerfrr owner's driver's license, form notarlza- proDettv owner's sionatu re. Signature of Property Owner hvo,* A as+o rona. a /v I zDzoDate: Print name of Owner a-4 L!)A a 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 peson(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit br my p@ect. Scope of Construction Project (or Description of Work) Project Location or Address: Name of Authorized Agent: Phone Number of Authorized Agent: 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 accuracy. Property Ownef s Signature:Date: Print Name of Owner: Note: A copy ol the owner's driver's license, form nobrlzafron, or other verification accephble to the agency is r* quired to be presented when the permit is issued to verily the propfi owner's slgnature.