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Revenue Service.the United States Small Business Administration.the California Department of Benefit Payments.and the California Division of Industrial Accidents.I also understand I may contact the California Contractors'State License Board (CSLB)at 1-800-321-CSLB (2752)orwww.cslb.ca.govformore information about licensed contractors. H;i10.I am aware of and consent to an Owner-Builder building permit applied for in my name.and understand ~I am the party lega"y and financially responsible for proposed construction activity. ~1.I agree that.as the party legally and financially responsible for this proposed construction activity,I will abide by a"applicable laws and requirements that govern Owner-Builders as we"as employers. ~2.I agree to notify the issuer of this form immediately of any additions.deletions.or changes to any of the information I have provided on this form.Licensed contractors are requlated by laws designed to protect the 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 may sustain as a result of a complaint.Your only remedy against unlicensed Contractors may be in civil court.It 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.If you obtain a permit as Owner-Builder and wish to hire Contractors,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 permit.Note:A copy of the property ownerls drivel'*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 ownerls signature. Property Owner Name (Printed)/I Lr£Irt){)tJ~:.::1'1 Phone:I..~f:-~61-YtJY Property Owner Signature !I[~C!.crr/Date:~-/{}-;J..0/I 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:/I1tJ&Le,/Io/}LC;~Lt4CE/J!t:!)JT APPtICA7llJA$;;..#/1111 Prol~?tJ:ocati_on or A3.5!ress:.2r~7 /ltkllfl./tf-t/~£[!Jc-,kTlJ~I (]A~ Name of Authorized Agent:/JjicI-!/-l&L..S'm /rl-l Phone:609'-b$-02..lik Address of Authorized Agent:j'.!tJ,~~?ClL/lt1e~el3lJ{M.~ry' I 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:_!....IJ:..,L...t{r-1trokr....L--"""'d'"-"'~_'__""_=____'="__Date:~-1f}-.2.0// F:\BUILOING\HANDOUTS\Owner Builder Verification Form.doc 2 of 2 (Revised 2-27-09)