BWFE2016-0142Applicant:
ANTHONY AMATO
52285 AVENIDA RUBIO
LA QUINTA, CA 92253
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:140528101254137829
Date: I 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 a
permit subjects the applicant to civil penalty of not more than five hundred dollars
A—A)oo)�,
-I; as owner of the property, or my employees with wages as their sole
compensation, will.do the work, and the structure is notintended 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
4h41,
or she 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 contractors) licensed pursuant to
4th Contractors' State License Law.).
( ,I am exempt under Sec. , B.&P.C. for this reason
Date.10 / Owner./.,4� r &0Pd 4m Al
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. Q.
Lender's
Lender's Address:
Contractor:
ANTHONY AMATO
52285 AVENIDA RUBIO
LA QUINTA, CA 92253
Llc. No.::CONV:140528101254137829
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 policy number are:
Carrier: Polity Number:
r` I 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
F
T
,� Z Applic04N
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 tothe 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 actor 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 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 -menti ned pr perty for inspection purposes.
D�ate:y� Z Signature (Applicant or Agent
a
VOICE (760) 777-7125
78-495 CALLE TAMPICO
0
FAX (760) 777-7011
LA QUINTA, CALIFORNIA
92253
-
COMMUNITY DEVELOPMENT DEPARTMENT
INSPECTIONS (760) 777-7153
BUILDING PERMIT.
Date: 6/27/2016
Application Number:
BWFE2016-0142
Owner:
Property Address:
52285 AVENIDA RUBIO
ANTHONY AMATO
APN:
773252014.
52285 AVENIDA RUBIO
Application Description:
AMATO / 51LF OF BLOCK WALL CAT REAR YARD
LA QUINTA, CA 92253
Property Zoning: .
Application Valuation:
$1,000.00
Applicant:
ANTHONY AMATO
52285 AVENIDA RUBIO
LA QUINTA, CA 92253
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:140528101254137829
Date: I 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 a
permit subjects the applicant to civil penalty of not more than five hundred dollars
A—A)oo)�,
-I; as owner of the property, or my employees with wages as their sole
compensation, will.do the work, and the structure is notintended 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
4h41,
or she 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 contractors) licensed pursuant to
4th Contractors' State License Law.).
( ,I am exempt under Sec. , B.&P.C. for this reason
Date.10 / Owner./.,4� r &0Pd 4m Al
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. Q.
Lender's
Lender's Address:
Contractor:
ANTHONY AMATO
52285 AVENIDA RUBIO
LA QUINTA, CA 92253
Llc. No.::CONV:140528101254137829
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 policy number are:
Carrier: Polity Number:
r` I 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
F
T
,� Z Applic04N
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 tothe 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 actor 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 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 -menti ned pr perty for inspection purposes.
D�ate:y� Z Signature (Applicant or Agent
19
Description: AMATO / 51LF OF BLOCK WALL 6' AT REAR YARD
Type: WALL/FENCE Subtype: CITY STANDARD/PRE- Status: UNDER REVIEW
Applied: 6/27/2016 SKH
APPROVED
Approved:
Parcel No: 773252014 Site Address: 52285 AVENIDA RUBIO LA QUINTA,CA 92253
Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 9 Lot: 3
Issued:
UNIT 1
52285 AVENIDA RUBIO
Lot Sq Ft: 0 Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $1,000.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
CONTRACTOR
Details: 51LF OF 5"/6' GARDEN WALL INSIDE REAR PROPERTY LINE [CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED
WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013.CALIFORNIA BUILDING CODES.
CONDITIONS
NAME TYPE
NAME
ADDRE551
CONTACTS
CITY. T2
$TATE
ZIP
y PHONE, FAX'' EMAIL-
APPLICANT
ANTHONY AMATO
52285 AVENIDA RUBIO
LA QUINTA
CA
92253
CONTRACTOR
ANTHONY AMATO
52285 AVENIDA RUBIO
LA QUINTA
CA
92253
OWNER
ANTHONY AMATO
52285 AVENIDA RUBIO
LA QUINTA
CA
92253
Printed: Monday, June 27, 2016 10:18:38 AM 1 of 2 ,
SYS TEtitS
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
RECEIPT#
CHECK #
METHOD
PAID BY
CLTD
BY.
WALL/FENCE - FIRST
101-0000-42404
0
$47.86
$0.00
100 LF
WALL/FENCE - FIRST
101-0000-42600
0
$60.91
$0.00
100 LF PC
Total Paid for FENCE OR FREESTANDING WALL: $108.77 $0.00
• 0• 00
INSPECTIONS
PARENT PROJECTS
Printed: Monday, June 27, 2016 10:18:38 AM 2 of 2 MANAF
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QUINTA
BUILDING & 86RFETY DEPT.
APPROVE®
FOR CONSTRUCTI N
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BUM1 ij, 8[ SA'iy-Mlsibn,
PA: Box 1504,-78-495.61if iamplco
La.Qulnta; CA 92253;-:(760) 777-7012
Building Permit App(rcatron and Tracking Sheet
Permit #
Project Addressi S Z:Z., . ✓�>U � ,. �
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Ownet's Natne:. ,rrr ,v
A P. Number.
Address S'zz.BS •N,✓,�. �8
Legal Description:
City, ST, Zip:
Contractor.
Telephone:.?'� �. :"........
Address:
Project Description:: .
City, ST, Zip:'
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Telephone:
P
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uOG�L . ( i9'�-�- A7 =State
Lic. # :
City Li,
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Arch., Engr., Designer
Address:
City., ST, Zip:
Telephone: P
State Lia #:• ' 'µyz
Goiistruction Type: Occupancy:
Project type {circle one): New Add'n Alter Repair Demo
Sq:, Ft.: # Stories: # Unity:
Name of Contact Person: iQ ,V j� MO
Telephone # of Contact Person:
Estimated Value of Project • d
APPLICANT: DO -NOT WRITE BELOW THI&LINE,
#
Submittal
&4 -dr
'Reed ,.
,TRACKDVG
PERMrr FEES
Plan Sets
Pian Check submitted . •
Item Amount
Structural Cales.
Reviewed, ready for coreecdons
Plan Cheek Deposit, .
Truss Calcs.
Called Contact Person
Plan Check Balance.
Title 24 Calcs.
Plans picked up
'Contraction
Flood plain plan
Pians resubmitted
Mechanical
Grading plan
2',° Reilew, ready for correcGonsAssue
Electrical
Subeoutactor Ids:
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.L
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''d Review; readyfor correctionslissae
Developer Impact Fee
Planning Approval
Coiled Contact Person
; A LP.P.
Pub: Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
BUILDING`& SAFETY -DEPARTMENT
78-4957CALLE.TAMPICO (760) 777-7012
LA' QUINIA, CALIFORNIA 92'253 FAX (760).777-7011
Considering Becoming an •Owner Builder?
Important information you needl-to` know BEFORE pulling your permit!
The term "Owner -Builder," can mean threedifferent things;:
"Owner as Worker ; "Owner as Contractor" or "Owner as Employer"
Understand each has Benefits or. Risk;. and itis possible to combine them!
Hiring a California Licensed :Contractor means you do, riot.personally perform.any of the comtructiori'work, the permit is not taken
out in your name, you are riot personally responsible for the construction and you are not an Owner -guilder. 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 workerinjury.
BenefiMsk: Ilij!hestBenefits and the Least amount ofRisk
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; woikmanship, aril completion of the job. You
benefit by not paying others to perform this work for you and your; risk dependsb6 your own ability'to coinplete the job successfully.
Benefit/Risk: Possible Benefit with Low -Financial Risk
Owner=as-Contractor is a type of Owner -Builder where. you personally actas your.own.General Contractor,. the permit istaken out in
your name and you hire California licensed sub -contractors to perform portion&of the.construction work. WARNING: The benefit of
protection provided "by law when you hire only' California licensed sub -contractors' can'"him to serious financial risk if you hire
unlicensed contractors to perform any of the work..
Benefit/Risk Possible`Benefit and'Significani Financial.Risk
Owner -as -Employer is iftype of.Owner-Buildei'-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.
Benefit4bski Possible Benefit with Sienificant Financial Risk
fy
(Health and Safety Code Section 19827) The California Legislature declares an "urgent and statewide
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 fled 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 ahead 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 1 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
ll
P.D. Box 1504
LA QUINTA;- CALIFORNIA 92247-1504
78-495 -CA-LLE.TAMPICO
LA. QUINTA, CALIFORNIA 92253
PROIPERTV�_OWNT
BUILDING &.SAFETY DEPARTMENT
(760)777-7012
FAX (760) 777-7011
Disclosures &Forms'for Owner -Builders Applying for' Permits
r n
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit.4s been submitted
Zy .,, ubmi'tted in your name. lik yourself as, the builder of the property
V,e,
improvements -specified at a.I-A 9ZZ
We are providing you with an Owner-B6ildei.;kclonbwl64iiiieAt and hiformation'Verificatibn Form to make you aware of your.
responsibilities and possible risk y6umay,in6iii by havig''.this' t- di .name as the
. _ perm; issue :mypur
Owner-Builde'r. Wemill notIs'sitie' a'hu-iildiQ. ... .... . ii 3,66 hav'�,read initialed itiAled yourlunderstanding of each provision,
signed; and returned this. form to usatour;officiah address indicated. Aii'a9 ent of the owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
Read and initial each.'statemeni,below to signify;
veiify -this information.
1. I 'understand a frequent pradtice. rt of 'unlicensed persons is to have the prope
I I .. , ry owner "obtain an "Owner -Builder"
building permit that erroneoiisl ' it roperty owner is providing or y implies that the r an
p lief 1�& and material personally. 1, as
an Owner -Builder, may be held liable and subject to serious firfancial risk for any mjunes, sustained by an unlicensed person
and his or her employees while working on my property.`?MjIomeowne,'s insurance may not provide coverage f6r those
injuries. I am willfully acting as an Owner -Builder and inn aw'Ai'6* of the limits of my insurance coverage for injuries to workers
on my property.
.AV2. I understand building permits arenotrequired to. be signed by property owners unless' they are responsible for the
construction . and are not hiring a licensed Contractor -to assume.this responsibility.
A3. I understand as an.6w;ner_Builder" I. am the, responsible -party of re"on the penut. I understand that I may protect
cord r
myself from potential financial risk by hiring a -licensed Conti -actor and having'I ihe:peniiit filed in his or her name instead:of my
-own.
144 4. 1 understand Contractors are required by law to be licensed'and bonded in California and to list'their license numbers on
permits and contracts.
.,"5. 1 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.
6. 1 understand if I am considered an "employer" under state and federafliwI must register with the state and federal
government, withhold payroll taxes, provide .workers' compensation disability
'ability insuiranbe,-- and contribute to unemployment
compensation for each "employee."' I also understand my failure',.',to abide by. these laws may su . bjec'
risk. t me to.s6rious financial
7. 1 understand under California* Contractors' State License.Law,* an'. Owner -Builder who builds single-family
ly residential
structures cannot legally build them with the . intent to
o offer them for sale, unless all work is perfo
imed by licensed
subcontractors and the number of structures does* not -exceed four within any calendar year, or of the work is performed
under contract with a licensed general- building Contractor.
.1"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
financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
Ii 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-
800-32 1 -CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
26-410. 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:
5-7
K v L i o G.,d 4?V;, , GA 9L2 Z
11. I 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 asmell 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
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. -7
Signature of property owne 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 persons) to act as my agent(s) to apply for, sign; and file the documents necessary to obtain an Owner -Builder
Permif 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 ver fcation
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: