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Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Acc'idents.,I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. L B 10. 1 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. L46 11. 1 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. L J 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the _in.for_matioxn_I_have_pravided_on-this_fo.rm--Lice-ns-ed-co-nfr_actor_s.are-reg-ulate-d-by laws_d.esi.gnad-to_pro#.ectlhe— public. If 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 m Wr It 1 I t only remedy against unlicensed-Contractors may be in civil court. It iso )P,�Pe r an unlicensed Contractor or employee of that individual or firm ispt ng on your pro you may be held liable for damages. If you obtain a permit as Owner-Builde . ' iI � Ii be responsible for verifying whether or not those Contractors are grope yr ers' compensation insurance coverage. two�I 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. Note. A copy of the property owner's alrlver's license, form notarization, or-other verlflcatlon acceptable to the agency is required to be presenters when the permit is issued to verify the property owner's signature. //�� -p.ropertyOwner Name (Printed) Zv.'S 9,:? Plone:('Zo'�) 7L/7-� 115 Property Owner Signature/ ,-,',"_ ,ga ZA, A,4 Date: JI//Z16 Authorization-Form_ is required to be completed by the property owner only-when designating an agent of the property owner to apply for a construction permit for the Owner-Builder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF 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 Work: Ae,-t7 o Z 04 Se Project Location or Address: 'Z3 /.5- lv. /wy /z Los' /C/-� 9 S Z c/Z Name of Authorized Agent:,,ar& ge1//,1rv1 crZAVocky Phone:C2o4, ) 7y7- !;�79 3 Address of Authorized Agent: Z 3 3 / 4J. /Z Loo`AL-,,f 5 Z y Z 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. ,Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. I have read and initialed items 1 thru 12 above. Property Owner's Signature Date: /home/rick/Users/Application Forms &Handouts/HANDOUTS/Owner Builder Verification Form.doc 2 of 2 (Revised 2-27-09)