BWFE2016-008578495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application Description:
Property Zoning:
Application Valuation:
Applicant:
JOVITA CARRION
54600 AVENIDA JUAREZ
LA QUINTA, CA 92253
Qumrcu
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
BWFE2016-0085
54600 AVENIDA JUAREZ
774263005
JOVITA CARRION / BLOCK WALL
11111111111111111111
79
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
JOVITA CARRION
54600 AVENIDA JUAREZ
LA QUINTA, CA 92253
DContractor:
JOVITA CARRION
20,J11 54600 AVEN I DA J UAR EZ
S LA QUINTA, CA 92253
CITYOFLA QUINTA
COMMUNIITY DEVELOPMENT DEPARTMENT
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.::CONV:140528301254078563
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 for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
PI, as owner of the property, or my employees with wages as their sole
ensation, will do the work, and the structure is hot 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 not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden of proving that
Fjg oyshe did not build or improve for the purpose of sale.).
I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (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 contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
JOAj.am exempt under Sec. __, B.&P.C. for this reason
Date: / Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a.construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.),
Lender's Name:
Lender's Address:
Date: 3/31/2016
(860)895-3617
Llc. No.::CONV:140528101254078563
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. My workers' compensation insurance carrier and polity number are:
Carrier: Policy Number: _
1 certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date:
Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO 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.
1 certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Date: 3/ �� Signature (Applicant or Agent): L
DESCRIPTION.' ,: -.
FINANCIAL ••
ACCOUNT- :: -
•
QTY; AMOUNT.;::
PAID .
PAID DATE
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
3/31/16
PAID BY ::
:METHOD
.:.RECEIPT.#.
CHECK #;':
CLTD.BY
JOVITA CARRION
CHECK
R14379
1003
RSE
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:
$1.00
$1.00,
DESCRIPTION
_ , ACCOUNT
QTY.
•: AMOUNT
PAID
PAID DATE
WALL/FENCE - FIRST 100 LF
101-0000-42404
0
$47.86
$47.86
3/31/16
PAID BY
- METHOD
RECEIPT #
CHECK #
CLTD BY .
JOVITA CARRION
CHECK
R14379
1003
RSE
DESCRIPTION-
A00OUNT'.
QTY
AMOUNT _
PAID
PAID DATE
WALL/FENCE - FIRST 100 LF PC
101-0000-42600
0
$60.91
$60.91
3/31/16
PAID BY
METHOD :.
RECEIPT #
.: •CHECK #
CLTD.BYG,.:
JOVITA CARRION
CHECK
R14379
T`-1003
RSE
Total Paid for FENCE OR FREESTANDING WALL:
TOTALS:0•
$108.77
$108.77
0•
Description: JOVITA CARRION / BLOCK WALL .
Type: WALL/FENCE Subtype: CITY STANDARD/PRE- Status: APPROVED
Applied: 3/31/2016 RSE
APPROVED
Approved: 3/31/2016 RSE
Parcel No: 774263005 Site Address: 54600 AVENIDA JUAREZ LA QUINTA,CA 92253
Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 271 Lot: 20
Issued:
UNIT 25
Lot Sq Ft: 0 Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $5,000.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
FAX
Details: 10OLF GARDEN WALL NORTH SIDE YARD [CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO,
PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013 CALIFORNIA BUILDING CODES
Printed: Thursday, March 31, 2016 9:47:00 AM 1 of 2
sys7rms
CONDITIONS
NAME TYPE
NAME
ADDRESS1
CONTACTS
CITY
STATE
ZIP
PHONE
FAX
EMAIL
APPLICANT
JOVITA CARRION
54600 AVENIDA
JUAREZ
LA QUINTA
CA
92253
(860)895-3617
CONTRACTOR
JOVITA CARRION
54600 AVENIDA
JUAREZ
-T-LA
LA QUINTA
CA
92253
(860)895-3617
OWNER
JOVITA CARRION
54600 AVENIDA
JUAREZ
QUINTA
CA
92253
(860)895-3617
Printed: Thursday, March 31, 2016 9:47:00 AM 1 of 2
sys7rms
DESCRIPTION
ACCOUNT '
QTY
AMOUNT
PAID
PAID DATE
RECEIPT #
CHECK #
METHOD
PAID BY
CLTD
BY
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
3/31/16
R14379
1003
CHECK
I JOVITA CARRION
RSE
Total Paid for BUILDING STANDARDS ADMINISTRATION
$1.00 $1.00
BSA:
WALL/FENCE - FIRST
101-0000-42404
0
$47.86
$47.86
3/31/16
• R14379
1003
CHECK
JOVITA CARRION
RSE
100 LF
WALL/FENCE - FIRST
101-0000-42600
0
$60.91
$60.91
3/31/16
R14379
1003
CHECK
JOVITA CARRION
RSE
100 LF PC
Total Paid for FENCE OR FREESTANDING WALL: $108.77 $108.77
TOTALS:•• •• .77
INSPECTIONS
PARENT PROJECTS
BOND INFORMATION
ATTACHMENTS
Printed:. Thursday, March 31, 2016 9:47:00 AM 2 of 2 CR
` SYSTFtiAS
� 0 W�c
Io V-. ve uj�V
CITY OF LA C UINT'A
BUILDING & SAFETY DEPT.
APPR0VED
FOR CONSTRUCTION
Ate, a0b BY
5K 1 SiiNir FCI-E C-!E;ONP-6
FOOTING OPTCON "A"
t
I
.H„ .
HEIGHT FROM TOP
OF FOOTING
12" 10"
FOOTING OPTION 6685"
#4 HORIZONTAL REBAR
(USE BOND BEAM BLOCK)
6" OR 8" BLOCK
#4. HORIZONTAL AT 32" MAX. O.C.
(USE BOND BEAM BLOCK)
SEE TABLE "A
— FOR REBAR SIZE
AND SPACING
(LOCATE REBAR IN CENTER OF CCLO
REVERSE
DIRECTION OF
HOOK ON EVERY (FOOTING WIDTH)
OTHER REBAR SEE TABLE "A"
"i'T'
„H„
„W„
VERTICAL
REINFORCEMENT
3'
17"
#4 @ 48" O.C.
4'
20"
#4 @ 48" O.C.
5' 1
23"
#4 @ 48" O.C.
6' 1
29"
#4 @ 24" O.C.
1
"H„
HEIGHT FROM TOP
OF FOOTING
SEETABLE "B"
FOR REBAR SIZE—
AND SPACING
(LOCATE REBAR IN CENTER OF CEIJJ
FINISH GRADE
(1) - #4 REBAR
—CONTINUOUS
_ (2) - #4 REBAR
Ti CONTINUOUS
ALL FOOTINGS ADJACENT TO
SLOPES TO BE AT LEAST 5' TO
DAYLIGHT AS SHOWN BELOW.
o "d
BorTOM AtI`
OF
FOOTING 5' MIN.
NOTES:
1) THIS DESIGN DOES NOT ALLOW GRADE DIFFERENTIALS OF
MORE THAN 6" ON OPPOSING SIDES OF THE
cllll=III
W. -%
(FOOTING WIDTH)
SEE TABLE "B"
CH ..0VYITH._Tt 1.E... U.&D,IN.0....DEPARTMENT TO
VERIFY IF A,.,BUIL�DING PERMIT.I$„REQUIRED.
NOT A RETAINING WALL. CITY Or Lit O 11V i .I{'j1�
2) FENCE HEIGHTS ARE REGULATED —CONSUL zgr�PfLDING & SAFE :
REGULATI
BEFORE BEGINNING CO TrO
PL
3) WATERONS COURSE OR NATURAL DRAINAGE HALL BAP P R V �/ �y,� ROM
OBSTRUCTED,. FOR CONSTR4/PF
4) GROUT ONLY THE CELLS CONTAINING RE R. THIS WALL VERTICAL RE
IS NOTD ESIGNED FOR ALL CELLS TO BEG UTED. /R 6gNG GR
5) ALL REBAR TO BE ASTM SPEC. A61 5, GRAAE 48�I �ib BY 3X1-1eRL; AFTI
6) ALL REBAR LAP SPLICES TO BE 24" MINIMU
7) ALL MASONRY UNITS TO BE ASTM C-90 GRADE N.
8) REBAR TO BE CENTERED IN MASONRY CELLS.
IS REQUIRED, THE FOLLOWING
TIONS ARE REQUIRED:
AVATION TRENCH CLEAN WITH
AND SUPPORTED 3” ABOVE AND
SURROUNDING EARTH/DIRT.
ROUT: BOND BEAM REBAR AND
2 IN PLACE - INSPECTION PRIOR TO
ROUT IS PLACED - PRIOR TO ANY
P PLACEMENT.
RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
'SEE PAGE 2 FOR ADDITIONAL INFORMATION' .
DISCLAIMER: r�
ALTERNATE. DESIGNS MAY BE POSSIBLE
WHEN PROVIDED WITH -AN ENGINEERED
ANALYSIS. USE OF THIS STANDARD DESIGN. CFw Oe T��
IS AT THE USER'S RISK AND CARRIES NO
IMPLIED OR INFERRED GUARANTEE AGAINST PliONG (760) 777-7125
FAILURE OR DEFECTS.
t<AX (760) 777-70.11.
T -dr 4 4Qur«rw
FREESTANDING BLOCK WALL:
78-495 CALLS TAMPICO
LA QUWTA, CALIFORNIA 92253
1019/2014 1 COMMUNf1Y DL•'VELOI'MENT DEPT. I PACE 1 OF 2
VERTICAL
REINFORCEMENT
3'
19"
#4 @ 48"
O.C.
4'
22"
#4 @ 48"
O.C.
5'
29"
#4 @ 48"
O.C.
6'
34"
#4 @ 24"
O.C.
CH ..0VYITH._Tt 1.E... U.&D,IN.0....DEPARTMENT TO
VERIFY IF A,.,BUIL�DING PERMIT.I$„REQUIRED.
NOT A RETAINING WALL. CITY Or Lit O 11V i .I{'j1�
2) FENCE HEIGHTS ARE REGULATED —CONSUL zgr�PfLDING & SAFE :
REGULATI
BEFORE BEGINNING CO TrO
PL
3) WATERONS COURSE OR NATURAL DRAINAGE HALL BAP P R V �/ �y,� ROM
OBSTRUCTED,. FOR CONSTR4/PF
4) GROUT ONLY THE CELLS CONTAINING RE R. THIS WALL VERTICAL RE
IS NOTD ESIGNED FOR ALL CELLS TO BEG UTED. /R 6gNG GR
5) ALL REBAR TO BE ASTM SPEC. A61 5, GRAAE 48�I �ib BY 3X1-1eRL; AFTI
6) ALL REBAR LAP SPLICES TO BE 24" MINIMU
7) ALL MASONRY UNITS TO BE ASTM C-90 GRADE N.
8) REBAR TO BE CENTERED IN MASONRY CELLS.
IS REQUIRED, THE FOLLOWING
TIONS ARE REQUIRED:
AVATION TRENCH CLEAN WITH
AND SUPPORTED 3” ABOVE AND
SURROUNDING EARTH/DIRT.
ROUT: BOND BEAM REBAR AND
2 IN PLACE - INSPECTION PRIOR TO
ROUT IS PLACED - PRIOR TO ANY
P PLACEMENT.
RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
'SEE PAGE 2 FOR ADDITIONAL INFORMATION' .
DISCLAIMER: r�
ALTERNATE. DESIGNS MAY BE POSSIBLE
WHEN PROVIDED WITH -AN ENGINEERED
ANALYSIS. USE OF THIS STANDARD DESIGN. CFw Oe T��
IS AT THE USER'S RISK AND CARRIES NO
IMPLIED OR INFERRED GUARANTEE AGAINST PliONG (760) 777-7125
FAILURE OR DEFECTS.
t<AX (760) 777-70.11.
T -dr 4 4Qur«rw
FREESTANDING BLOCK WALL:
78-495 CALLS TAMPICO
LA QUWTA, CALIFORNIA 92253
1019/2014 1 COMMUNf1Y DL•'VELOI'MENT DEPT. I PACE 1 OF 2
FOO
DESIGN -PARAMETERS:
ACTIVE SOIL PRESSURE (PSF) =30
PASSIVE SOIL BEARING (PSF) =150
COEFFICIENT OF FRICTION = 0.25
ALLOWABLE SOIL BEARING (PSF) =1500
WIND = 80 MPH. EXPOSURE C
SEISMIC:
NA= 1 .3. Nv= 1.6. Z=0.4, SOIL PROFILE=SD
WESTERN RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
4
eq CV
c
4 '
v
FREESTANDING BLOCK WALL
OF il1F
PHONE (760) 777-7125 78-495 CALLS TAMPICO
LA QUIN'lA, CALIFORNIA 9'2'253
FAX (760) 777-7011 10/9/201 ry COMMUNITY DEVELOPMENT DEPT. LIGE 2 OI' 2
Bin #
City of La Quinto
Building &r Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
pis Building Permit Application and Tracking Sheet
Permit #
LdvEz —
Project Address:gig &-eUzz v
Owner's Name:��V
A. P. Number:
Address: 5 L�
Legal Description:
City, ST, Zip: Q ��
Contractor: o
hon
Telephone:
e. S— /
Address: 9.
Project Description:
City, ST, Zip: a
Telephone:
State Lie. # :
City Lie.
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone: one:
Con truct�o n Type: Occupancy:aneY
Stoto Lic. #•
RePai
r DemoPioJect type Addn Alter
Name of Contact Person:
Sq. Ft.: r tiQ
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
tt
Submittal
Req'd
Rcc'd
TRACKING
PERMIT FEES
Plan Scls
Plan Check submitted
Item.
Amount
Structural Cafes.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cafes.
Called Contact Person
Plan Check Balance.
Title 24 Cafes.
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.
1-I.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"'• Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
t�
Total Permit Fees
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 een submitted your name listing y self as the builder of the property
improvements specified at(/G>� of
We are providing you with an Owner -Builder Acknowledidiient and InflKimtion. V rification 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, initiated 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.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signs you understand or verify this information.
,(i 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
uilding permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, 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 my property.
C. 2. I understand building permits are not required to be signed by property owners unless they are responsible for the
construction 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
myself.from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
p4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
ermits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
g6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
overnment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by .these laws may subject me to.serious financial
risk/.
Cf, 7. I understand under California Contractors' State License Law, an. Owner -Builder who builds single-family residential
structures 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.
Lncial
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
or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
Cl 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.
,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., rancially ,responsible for proposed construction activity at the' following address:
11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirement$ that govern Owner -Builders as.well as employers.
t�r12. I agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the information I
V 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 agency responsible for issuing the permit. Note: A copy of the property 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.
r, r
Signature of property owner Date:
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:
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 permit is issued to verify the property owners signature.
Property Owner's Signature: Date: