BELC2014-105253160 Avenida Madero
BELC2014-1052
°awVOICE (760) 777-7125
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS 760) 777-7153
{ i . COMMUNITY DEVELOPMENT- DEPARTMENT
BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: License No.:
Date:
Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3
of the Business and Professions Code) or that he or she is exempt therefrom and the
basis Pr the alleged exemption. Any violation of Section 7031.5 by any applicant for a
per subjects the applicant to a civil penalty of not more than five hundred dollars
($5 I•:
f,,as owner of the property, or my employees with wages as their sole
o ensation, will do the work, and the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the improvements
are'intended or offered for sale. If, however, the building or improvement is sold
withi one year of completion, the owner -builder will have the burden of proving that
he she did not build or improve for the purpose of sale.).
( I, as owner of the property, am exclusively contracting with licensed contractors
co truct the project. (Sec. 7044, Business and Professions Code: The Contractors'
tate icense Law does not apply to an owner of property who builds or improves
th n, and who contracts for the projects with a contractor(s) licensed pursuant to
t ontractors' State License Law.).
am exempt under Sec. B.&P.C. for this reaso
Date Ow r.
CONSTRUCXON L ING GENCY L/
I hereby affirm under penalty of penury that they nstruction lending agency for.
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's
Lender's
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued.
_ I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of.the work for which this permit
is issued. orkers' compensation insurance carrier and policy number are:
CA—qier: Policy Number: _
'Icertify that in the performance of the work for which this permit is issued, I
employ any person in any manner so as to become subject to the workers'
c pensation laws of California, and agree that, if I shou becom ubject to the
workers' compensation provisions of Sectio 7 0 of a Labo I s th
comply with those rovisions. f
Date: i Applicant
WARNING: FAILURE TO SECURE WORK S' COMPEN ATIO VERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose
request and for whose benefit work is performed under or pursuant to any permit
issued as a result of this application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is
not commenced within 180 days from date of issuance of such permit, or cessation of
work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above informati is correct.
I agree to comply with all city and county ordinances and state laws rela i g to building
construction, and hereby authorize representatives of is it to ent upo a above•
mentioned property for inspection purposes.
Date Signature (Applicant or A en
Date: 12/4/2014
Application Number:
BELC2014-1052
Owner:
Property Address:
53160 AVENIDA MADERO
REX AND JACKLINE SLEZAK
APN:
774032023
53160 AVENIDA MADERO7uz
Application Description:
UPGRADE EXISTING 125AMP PANEL TO 200AMP PANEL
LA QUINTA, CA 92253
Property Zoning:
Application Valuation:
$1,100.00
Applicant:Contractor:
1ACKLINE SLEZAK
JACKLINE SLEZAK53160
AVENIDA MADERO
53160 AVENIDA MADEROLA
QUINTA, CA 92253
LA QUINTA, CA 92253
(760)771-3992
LIc. No.:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: License No.:
Date:
Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3
of the Business and Professions Code) or that he or she is exempt therefrom and the
basis Pr the alleged exemption. Any violation of Section 7031.5 by any applicant for a
per subjects the applicant to a civil penalty of not more than five hundred dollars
($5 I•:
f,,as owner of the property, or my employees with wages as their sole
o ensation, will do the work, and the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the improvements
are'intended or offered for sale. If, however, the building or improvement is sold
withi one year of completion, the owner -builder will have the burden of proving that
he she did not build or improve for the purpose of sale.).
( I, as owner of the property, am exclusively contracting with licensed contractors
co truct the project. (Sec. 7044, Business and Professions Code: The Contractors'
tate icense Law does not apply to an owner of property who builds or improves
th n, and who contracts for the projects with a contractor(s) licensed pursuant to
t ontractors' State License Law.).
am exempt under Sec. B.&P.C. for this reaso
Date Ow r.
CONSTRUCXON L ING GENCY L/
I hereby affirm under penalty of penury that they nstruction lending agency for.
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's
Lender's
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued.
_ I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of.the work for which this permit
is issued. orkers' compensation insurance carrier and policy number are:
CA—qier: Policy Number: _
'Icertify that in the performance of the work for which this permit is issued, I
employ any person in any manner so as to become subject to the workers'
c pensation laws of California, and agree that, if I shou becom ubject to the
workers' compensation provisions of Sectio 7 0 of a Labo I s th
comply with those rovisions. f
Date: i Applicant
WARNING: FAILURE TO SECURE WORK S' COMPEN ATIO VERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose
request and for whose benefit work is performed under or pursuant to any permit
issued as a result of this application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is
not commenced within 180 days from date of issuance of such permit, or cessation of
work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above informati is correct.
I agree to comply with all city and county ordinances and state laws rela i g to building
construction, and hereby authorize representatives of is it to ent upo a above•
mentioned property for inspection purposes.
Date Signature (Applicant or A en
t
Bin 1r
'
Permit #`
FPcojeet Address: — I
City of La Quinto.
-Building $t: Safety Division
P.O. Box 1504, 78-495 Calle Tampico .
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
XOwner's Name: 9 t
A. P. Number:
=Address:
Legal Description:
City,.ST, Zip:
Contractor:
t
Telephone:// —
l0
"''•<>'' '"'`
Address:
ea
__Project Description: P_ S
City, ST, Zip:
Telephone:
P ne•sm =Nw
- 'a D
State Lic. # :
City Lic. #: j
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
aneY
Construction Type: Occupancy:
•
State Lic. #
Project.type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone #,of Contact Person:
=Estimated-Value of Project: V
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES.
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs..
Plans picked up'
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2°" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up '
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'rd Review, ready for correction srissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
!
Total Permit Fees
FINANCIAL INFORMATION
DESCRIPTION xr° ` s
•,.tY� F.t .r. r s �. ACCOUNT„�x� %'' 4 %QTY ,.AMOUNT_,.;t s int,.:..•' PAID �'�
PAID'DATE
BSA B14;13 FEE 101-0000-20306 0
$1.00 $0.00
-1�
r - P. BY ?: r t . }s METHOD tars: Fj .RECEIPT•# . `�CHECK #k rI
CLTD BYrt,
Total Paid forBUILDING STANDARDS ADMINISTRATION BSA $1.00 $0.00
DESCRIPTION
;t
OUNT -
PAD
DATEACCOUNT
'PAID
SERVICES
101-0000-42403
0
$24.17
$0.00
��: PAID,BY sz . ..-:'
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?:bESCRIPTION `«
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:. !7 . -ACCOUNT .:
QTYr�
AMOUNT +�, x
t < aY;
PAID ..w
PAID, DATE
SERVICES PC
101-0000-42403
0
-$12.09
$0.00
MET HOD' ' '
'*SAS *RECEIPT#� r
°T' sCHECK#
CLTD'BY
'Total Paid for ELECTRICAL: $36.26 $0.00
DESCRIPTION ., k = «
01 rt� _
'� ACCOUNT
QTY*
�~
AMOUNT ,r'
PAID ” `
Dre
PAID-DATE':
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$0.00
�r PAIDµB t i , ��
:. r' METHOD
RECEIPT•#asi
CHECK'#
CLTD BY
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
TOTALS:•-
r-
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Off. - ;• i ..:£ �++�t s 1": '0' !e� y,yti,�. • .r p -i . , ..".i a •»r -� '+
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Description: UPGRADE EXISTING_ 125AMP PANEL TO 200AMP PANEL
Type: ELECTRICAL
Subtype:. - Status: APPROVED
Applied: 12/4/2014 SKH
Approved: 12/4/2014 SKH
Parcel No: 774032023 t Site Address: 53160 AVENIDA MADERO LA QUINTA,CA 92253
Subdivision: SANTA CARMELITA VALE LA QUINTA ; Block: 179' Lot: 17
Issued:
UNIT 18
s
53160 AVENIDA LA QUINTA
Lot Sq Ft: 0
Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $1,100.00
Occupancy Type: Construction Type:
Expired:
No. Buildings: 0
No. Stories: 0 No. Unites: 0
Details: ELECTRICAL -UPGRADE
EXISITING 125 AMP PANEL TO 2000 AMP PANEL. 2013 CALIFORNIA BUILDING
CODES.
•
MNAME`TYPE+ '$ `NAME ar �c:�r� a'.iAD,DRE551' P CITY a�
sSTATE ZIP
.P,HONE r ='FAXt
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E 4.: �S--.f'�S* ,' d'.. �s,�•,1�• Y -r - ..a, .N _ _
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-
APPLICANT. JACKLINE SLEZAK
53160 AVENIDA LA QUINTA
CA
92253
(760)771-3992
- MADERO
CONTRACTOR JACKLINE SLEZAK
53160 AVENIDA LA QUINTA
-CA
92253
(760)77173992
MADERO
OWNER •REX AND JACKLINE SLEZAK •
53160 AVENIDA LA QUINTA
CA
'92253
(760)771-3992
-
MADERO
` C •
FINANCIAL • •
Printed: Thursday, December 04, 2014 3:39:29 PM 1 of 2 CRWsrsrEMs
PARENT PROJECTS
REVIEWS
T.
RETURNED �-kEMARKS'
T
-REVIEW TYPE 4DUE D�TE��. NOES
R 1.� " STAttis
t
-REVIEWER,- PATE
t7f
BOND
INFORMATION
--CHECK
METHOD
PAID B,Y-,
CETD:"
DESCRIPTION:
ACCOUN T"
QTY
.,AMOUNT.
PAID
PAID DATE
RECEIOT#'
BY
BSAS SB1473 FEE
101-0000-20106
0
$1.00
$0.00
Total Paid for BUILDING STANDARDS ADMINISTRATION
$1.00 $0.00
BSA:
SERVICES
101-0000-42403
0
$24.17
$0.00
SERVICES PC
101-0000-42403
0
$12.09
$0.00
Total Paid for ELECTRICAL: $36.26 $0.00
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$0.00
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
TOTALS: $129.11 $0.00
PARENT PROJECTS
REVIEWS
T.
RETURNED �-kEMARKS'
T
-REVIEW TYPE 4DUE D�TE��. NOES
R 1.� " STAttis
t
-REVIEWER,- PATE
Printed: Thursday, December 04, 2014 3:39:29 PM 2 of 2 CB?w1YSTEMS
BOND
INFORMATION
ATTACHMENTS
Printed: Thursday, December 04, 2014 3:39:29 PM 2 of 2 CB?w1YSTEMS
I
TAh
ull'%iCv
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT
78-495 C'ALLE TAMF ICO (7 60) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
ConsideringBecoming an Owner -Builder?
E
Important information you need to 'know BEFORE pulling your permit!
The term "Owner -Builder" can mean three different things:
"Owner as Worker", "Owner as Contractor" or "Owner as Employer"
Understand each -has Benefits or Risk, and it is possible to combine them!
Hiring a California Licensed Contractor means you do not personally perform any of the construction work, the permit is not taken
out in your name, you are not personally responsible for the construction and you are not an Owner -Builder. Instead, you become a
"Customer" and California law provides you the benefit of protection from poor workmanship, failure to finish the job and financial
risk due to worker injury.
Benefit/Risk: Highest Benefits and the Least amount of Risk
Owner -as -Worker is a type of Owner -Builder where you personally perform the construction work, the permit is taken out in your
name and you are personally responsible for the construction management, knowledge, workmanship, and completion of the job. You
benefit by not paying others to perform this work for you and your risk depends on your own ability to complete the job successfully.
Benefit/Risk: Possible Benefit with Low Financial Risk
Owner -as -Contractor is a type of Owner -Builder where you personally act as your own General Contractor, the permit is taken out in
your name and you hire California licensed sub -contractors to perform portions of the construction work.. WARNING: The benefit of
protection provided by law when you hire only California licensed sub -contractors can turn to serious financial risk if you hire
unlicensed contractors -to perform any of the work.
Benefit(Risk: Possible Benefit and Significant Financial Risk
Owner -as -Employer is a type of Owner -Builder where you pay any unlicensed individual to perform any construction work valued at
more than $500.00, the permit is taken, out in your, name and you are personally responsible for their employment requirements,
supervision, performance, safety and welfare while on your property. WARNING: Cost savings benefit can turn to serious financial
risk if you fail to deduct payroll taxes or provide workers compensation insurance for each worker.
Benefit/Risk: Possible Benefit with Significant Financial Risk
(Health and Safety Code Section 19827) The California Legislature declares„an "urgent arod-ttatewide
public interest in assuring” that contractors comply with Contractors' License Law, Business and .
Professions Code and Workers' Compensation Insurance requirements to ensure property owners are
informed about, and protected from the following when improving their property as Owner -Builders:
Fraudulent representations - Liability for worker's injuries • Liability for material and labor costs unpaid by
contractors - Licensing requirements - Employers tax liabilities
Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects
and include workmanship and workers' compensation issues .Homeowners suffer financial harm due to
defective workmanship and injured employees.
Following are alarming examples of what has occurred with Owner -Builder permits:
Example 1: Homeowner received insurance money to rebuild burned -down home.
• Owner/Builder permit pulled to rebuild structure.
• Unlicensed contractor built substandard structure — must be torn down and replaced.
• Estimated financial injury is $225,000.
• Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of
the year.
Example 2: Brother-in-law had active license but filed an exemption from Workers Comp.
■ Owner -Builder hires brother-in-law to install a new roof.
■ Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and
remains in a coma to this day.
■ The Owner -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for
benefits paid to the injured worker.
Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic
system and suffers injury that results in permanent disability.
■ The Owner -Builder did not have a homeowner's insurance policy on the house against which to submit
a claim.
■ The Owner -Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured
worker.
Did you know — unlicensed persons frequently have the property owner obtain an "Owner -Builder' building
permit which erroneously implies that the property owner is providing his or her own labor and material
personally?
Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your
property by an unlicensed contractor and his/her employees?
Did you know — if you are considered an "employer" under state and federal law, you must register with
the state and federal government, withhold payroll taxes, provide workers compensation and disability
insurance and contribute to unemployment compensation for each "employee"?
Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk?
OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR
YOUR CONSTRUCTION PERMIT
P.O.. BOX 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA- QUINTA, CALIFORNIA 92253
BUILDING & SAFETY. DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760)777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted }�i your name (list* ourself as the builder of the property
improvements specified at 53 ^ J % D !Y I1�P n I /',lCt /�f ll (D ! a h i U& �%A . �% a2 a.(3
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make. you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. 'We will not issue a building permit until you have read, initialed your understanding of each provision,
signed, and returned this form to us.at our official address. indicated. An agent of the owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
R'S
Read and initial each statement below to signify you understand or verify this information.
r 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-Builder"
building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as
an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those
injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on y property.
2. I understand building permits ' are not required to be signed by property owners unless they are responsible for the
onstruction and are not hiring,a licensed Contractor to assume this responsibility.
3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
elf from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
fd2;
. I understand Contractors are required by law to be licensed and bonded. in California and to list their license numbers on
ts and contracts.
. I understand if I employor otherwise engage any persons, other than California licensed Contractors, and the total value
construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
state and federal law.
. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
mment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
ensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
.
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
res cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
?` 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
nancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
°wor nship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
ervice, 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 I-
800-32 1 -CSLB
-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
a legally and financially respons'bl for prop sed construction activity at the following address:
1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
cable laws and requirements that govern Owner -Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
piovided 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 agency responsible for issuing the permit. Note: copy o he property owner's driver's license, form notarization, or
other verification acceptable to the a is requi ed to p ented whe the permit is issued to verify the property
owner's signature.
Signature of property o €r Date:
Note: The followingtthorization 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:
Name of Authorized Agent:
Address'of Authorized Agent:
Tel No
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 pennit is issued to verify the property owner's signature.
Property Owner's Signature: Dater