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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) or www.cslb.ca.gov for more information about licensed contractors. I?C- 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. r!�11. 1 agree that, as the party legally and financially responsible for this proposed co!astruction activity, 1 wili abide by-all applicable laws and requirements that govern Owner-Builders as well as employers. P�12. 1 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 regulated 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 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' c—cmPensauo-n 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. Nate,- A copy of the property owner's driver's /scene, form notarization, or other ve;-ification aAcceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature, Property Owner Name (Printed) �_- r,,.�c( ( Phone: Property Owner Signature ;/ Date: Authorization Form is regr.,ired to be completed by-the property owner only when designating an agent of the property owner to app(v_for a construction permit for the Owner-Builder. AUTHORIZATION 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: 5 ;Z r ff Project Location or Address: 26 (�° )� / > 4 41 Name of Authorized Agent: �L % r �- ->, ,v� 1, Phone: �PV2 Address 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. 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 signatur I have read and initialed items 9 thru 92 above. Property Owner's Signature: P Date: F:\Application Forms&Handouts\Building Forms and Handouts\Owner Builder Verification Form 2-2009.doc 2 of 2 (Revised 2-27-09)