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OSOyl Jo; 962JOA00 ap!Aad Iou Aew aoue*Jnsui sjaumoewoy fVj -llJado*Jd /w uo 6upppom a!!ym saa6o!dwe jay jo sly pus uosied pasueogun us Aq pau!elsns saunfu! Aue lo; Msu le!oueug snopas of Ioefgns pus alge!l play aq Aew '*Japl!ng-*JaumO us se 'I 'Alleumad leualew pus jogel umo *Jay *Jo sly 6ulpinad sl jaumo ,(ljadad ayI Ieyl sa!idw! AIsnoeua*Ja Ieyl I!wad 6ulplmq ,yappne-jaum us welgo jaumo Apadad ayI aney of si suos*Jad pasuaogun;o ao!;oe*Jd Iuanbai; a puels*Japun I 'I vogewao;ui sfyl Aj!jan jo puelvapun noAlqiuft of molaq luawa;e;s yoea fegfuf pus peen :SNOIlO al0 NOI1VWUO:IN1 j0 NOLLV31d183A aNV 1N3W9a37lMONHOV S,M3NMO -Aj!joglne 6u!II!w*Jad ayI ;o Ienadde *Joud ay; welgo '*Jaumo LI/adad ayI 'no,( ssalun sogou s!yl alnoaxe Iouueo jaumo ayI;o Iua6e uy paieo!pu! ssauppe lelolgo mo is sn of wjo; s!yi pawniai Pus 'pau6!s `uo!s!nad yoea;o 6ulpueisiapun moR pale!iIu! 'peaU aney nog( 1!iun i!wjad 6u!pl!nq a anssl iou 111m aM '*Japlmg-jaumO ayI se aweu *JnoA u! panss! I!w*Jad sly3 6u1Aey Aq *Jnou! Aew noA Asp alq!ssod pus sa!ll!cilsuodsa*J ino6;o a*Jeme nog( aNew oI wjo=j uolleoyuan uogewJo;ul pus Iuaw6palmou�oy *Jap!mg-*JaumO us qj!m noR 6wp!Awd aje aM %7Z b 'r» rry 0 Q 0 /, le pa!;!Dads sluawanadw!ll�adad ayi ;o *Japinq ayI se;lasinoA 66 g aweu *JnoA ut pa)A!Ltfqns uaaq sey liwad bu!p!mq a *Jo; uogeo!ldde uy :*JaumO AVadwd JeaO 113NMO Alil3dONd 01331ION OOZ£-4b9 (666) I Ao 'eoyoeagl,o mau mmm 9668-899Z6 d0 'yoeag IJodmaN 189L1, xog •O•d I anu(] *Jalua0 oIA!O 00l KOISIAIQ Dm(trlIf18 .LN12[W LHVddQ .LIB RWdOrI51A3U A.LINfINW03 H3V2tg ,LHOdAA:4AI d0 AZI3 P)lLg. 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 /peke information about licensed contractors. N 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and 0 un—derstand that I am the party le ally and finance ly responsible for proposed cons ru tion activity at the jollowingaddress: ��fl�f vocd�F „c ?�7a7 .�¢y� � &e k 111agree that, as the party legally and financially responsible for this proposed construction ty,Iwill abide by all applicable laws and requirements that govern Owner -Builders as well as oyers. 12. 1agree to notify the issuer of this form immediately of any additions, deletions, or changes to f 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 owner 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 presented when the permit is issued to verify the property owner's signature. Print name of property owner: Property Owner's eS Date: 3- 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): M Project Location or Address: ,t w 43 C. , v �+ Name of Authorized Agent: a 3 �cty e JTel No Address of Authorized Agent: ///0 ir 14-u i cj&AG CtA -u 2 C%Gi �ii nW. �etv Q 2 4GG 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 properly owner'ssignature. Property Owner's Signature: - ��— Date: 3 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 9wner's signature. Foms\o oer builder verifdoc 08/12/16 - 2 o- 2