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Home My WebLink AboutX2021-2708 - Misc (7)ZpC) I 9l/ZI/80 oop;uan 1appnq i ohs oA -sleua;ew jo diysuew�joM ay; ui s;oa;ap uoi;onj;suoo;ua;el Aue wojp }lnsaj }ey; (s)jauMo }uenbasgns Aue Aq pauie}sns saunfui leuosiad jo leioueug Aue jop algep play aq new 1 'penssi si ;!wad sly; yoigm jo; A;Jadoid ay; pas I pi aappng-jaumo ue se pue;saapun 1 -11 •1010eJ;u00 buippnq lejaua6 pasuaoll a q;lnA }oej}uoo aapun pewjoped si NioM ay} jo Ile jo 'jean( jepualeo Aue uigl!m ino; paeoxe ;ou seop sompni;s ;o jagwnu ay; pue sjo;oei;uoogns pasueop Aq pawo;Jad si NjoM lle ssalun 'ales jo; way; jago o;;ua;ui ay; y;iM way; ppnq Allebal ;ouueo sain;onj;s lei;uaplsaj Alpe;-albuis spllnq oyM jappng-jauMO ue 'Aneq asueoi-I a;e;S siolowliloo eiwo;lle0 japun pue;siapun 1 'L- -Nsu leloueug snouas o; aw;oafgns Aew sMel asay; Aq aplge o; ajnpe; Aw pue;sjapun osle I „-9aAoIdw9„ yoea jo; uoi;esuadwoo;uawAoldwoun o; a;nqu;uoo pue 'aouejnsui Al!l!gesip uoi;esuadwoo sJONJOM apinad 'saxes paAed ploggjIm ';uawwano6 leJapa; pue a;e;s ay; y}iM ja;si6aa ;snw 1 'noel lejapap pue a;e}s lapun ,deAoldwa„ ue pajapisuoo we 1 pi pue}siapun I '9� -Mel lejapap pue a}e}s japun ,daAoldwa„ ue pajapisuoo aq Aew 1 'sleua;ew pue jogel 6uipnloui '(OOg$) sjepop paipuny aAi;;seal }e si uoi}ona;suoo Aw jo enleA le;o; all pue 'sio}oei;uo0 pasuaoll elwo;ile0 uey; jay;o 'suosiad Rue ebe6ua asinvay;o jo Aoldwo 1 ;i pue;slapun 1 -gv •s;owiuoo pue s;iwjad uo sjegwnu asueoil nay} ;sil o; pue eiwopile0 ui papuoq pue pasuaoll aq o} Mel Aq pannbei aie sio;oei;uoo pue}siepun 1 'bj •uMo Aw jo pea}sw aweu jay jo sly ui paiq }iwjed ay; 6uiney pue jo;owillo0 pasuaop a 6uuiy Aq Isu legueui; lei;uelod was ;Ies/Iw ;oa;ad Aew 1 ;ey; pue;siepun 1 '31wwad ay} uo pjooai jo Ailed algisuodsaj ay; we 1 ,jsppnq-jaumo„ ue se pue;slapun 1 E J O .A;ipgisuodsai siy; awnsse o; jo}oej;uo0 pasuaoll a 6uuiy sou eje pue uoi;onj}suoo ay; Jo; alglsuodsai aje Aay; ssalun sjauMo Alloclad Aq paubis aq o; pannbei jou aie s;iwad 6uippnq pue;siopun 1 •Z--j -Aliedad Aw uo sia>I;oM o; saunfui Jo; 06eJan03 eouelnsui Aw jo s;iwil ay; jo aleMe we pue japling-jeuMO ue se bul;oe Al1rp ip we 1 saunfui asoy} Jo; 96eJanoo apinad }ou Aew eouejnsui spuMoewoy Ainl -Apadoid Aw uo 6uiNjoM el!gm saeAoldwe jay jo siy pue uosied pasueopun ue Aq pauie;sns saunfui Cue jop >Isu leloueulp snouas o};oafgns pue algeil plaq aq new 'japling-jeuMO ue se 'I •Rpeumad leua;ew pue jogel uMo Jay, o Sly 6uipinad si jeuMo Aped6id ay};ey; sapdwi Alsnoauowa;ey};iwad 6uiplmq „l9ppng-iaumo„ ue a-rl;o jeuMo Aliedad ay; aney o; si suosled pesueoilun jo eoi;oeid ;usnbaj; a pue;sjapun I uogewaopul sly; djuaAjo pugsiapun nolt tflluft q Molaq;uawa;e;s goea Iel;lw pue peen :SN0110381O .v NOI1VWMO=IN1 d0 NOUVOIdIa3A aNV 1N3N156371MONNOV S,M3NMO -Ajpoy;ne 6ug;lwiad ay} ;o lenadde joud ay} uie;go 'jauMo Aliodad ay; 'nog( ssalun aoisou siy; a;noexe ;ouueo lauMo ay} po;uabe UV •pa;eoipui ssauppe leloigo ino;e sn o; wjo; siy; poum;au pue `pau6is 'uoisiAoud yoea ;o 6uipue;suapun JnOA pole);lui 'peaj aney noR 11;un ;lwjad 6uiplmq a anssi sou Illm aM aappng-�auMO ay} se aweu jnoA ui ponssi ;iwaad sly} 6uiney Aq moui Aew nog( > su algissod pue sei}iliglsuodsei moA po ejeme nog( a> ew o} O� uogeoi;uan uoi;ewo; 1 pue ;ua 6p9ImouNoV jappng-jeuMO ue y;lM nog( 6uipinaM d eje a C,'�o 1j f w�o -dAVT It, ;e pai;loads s}uawanoidwi (uadad ay} ;o jappnq ay} se plosinoA 6ui}sil aweu jnoA ui pepiwgns uaeq sey }iwied 6uiplinq a jop uoi}eoildde uV :aauMO �Ijadad reap 1d3NMO J11M3dOMd 0130110N 5Z866 OSH W3A NOUV1M2iO3N1 (INV 1NMN39a3lMONMOV U3a-im-UMMO OOZE-17179 (6176) 1 Ao eoyoeeq;ao Mau MMM 9168-899Z6 VO `yoeag;rodm9N 199L I, xog 'O'd I anup Ja;u90 o1A10 001, NOISUM 91,IIQ11flg suHIaixva2[a suHWaOzAAHa AiINfINW00 HDVIR ,LHOJAA,:IN 30 ALI3 PG 9. I understand I may obtain more information regarding my obligations as an "employer' from the Internal 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.csib.ca.gov for more information about licensed contractors. h10. 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 at the following address: L112 �C�lotro�e Ay�l Corcrt� uel Mares q� 6as —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. P12. 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 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 owrer and returned to the City of Newport Beach, Building Division, for issuing the permit. Note: A copy of the property owner's driver's license or form notarization is required to be prusented when the permit is issued to verify the property owner's signature. Print name of property owner: PAP-MZ ►T S •• G9JF W A� Propertv Owner's Signature: _12,JL 6!QDate: 1010510.1 Note: the following 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 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 the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Fc 411 V \1o{ roM n Ave -, Coco a'Dek 1nar, , q aCa.S Name of Authorized Agent: ke-wo+L S. G"wAL Tel No —82,Z2 Address of Authorized Agent: 14206 MiriSOi t -jf✓it'te,1 CDC• Q2.620 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. Property Owner's Signature: Date: I 0 1 0.5 1A 1 Note: A copy of the owner's driver's license or form notarization is required to be presented when the permit is issued to verify the property owner's signature. Forms\owner builder verifdoe 08/12/16 2 of 2