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BWFE2015-0080LICENSED 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.: 61e: 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 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 permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: (� I, as owner of the property, or my employees with wages as their sole compensation, 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 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 he or she did not build or improve for the purpose of sale.). (1 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 pioperty who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). I ) I am exempt under Sec. . B.9,P. . for this reason , Date: Own r CLENDING 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: LIC. No.: WORKER'S COMPENSATION DECLARATION I. 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: 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 tha,tl I should become subject to the workers' compensation provisions of Section 0 of the Labor Code I ort with comply with those provisions. Date: qkc ADollcan 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 perfgrmed 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 t above information is correct. I agree to comply with all city and county ordinances state laws relating to building construction, and hereby authorize represeItaivesf is city to enter upo omentio pro ert�for inspection -purpose Date: Signature (Applict 4 aw VOICE (760) 777-7125 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 4/28/2015 Ap lication Number: BWFE2015-0080 Owner: Property Address: 46405 CAMEO PALMS DR CONSTANCE KASH _..'A0 Ot � L�-\u APN: 643181018 Property Zoning: APR 9 2 8 2015 Application Valuation: $1,500.00 %ITY OF LA UINTA Applicant: Contractor: C0(?kIUNITYOEVELOP(r1cvTOEPARTOIENT CONSTANCE KASHKAWOL "-- 50325 VIA AMANTE 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.: 61e: 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 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 permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: (� I, as owner of the property, or my employees with wages as their sole compensation, 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 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 he or she did not build or improve for the purpose of sale.). (1 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 pioperty who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). I ) I am exempt under Sec. . B.9,P. . for this reason , Date: Own r CLENDING 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: LIC. No.: WORKER'S COMPENSATION DECLARATION I. 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: 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 tha,tl I should become subject to the workers' compensation provisions of Section 0 of the Labor Code I ort with comply with those provisions. Date: qkc ADollcan 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 perfgrmed 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 t above information is correct. I agree to comply with all city and county ordinances state laws relating to building construction, and hereby authorize represeItaivesf is city to enter upo omentio pro ert�for inspection -purpose Date: Signature (Applict FINANCIAL INFORMATION DESCRIPTION ACCOUNT, QTY. AMOUNT PAID PAID DATE BSAS SB1473 FEE 101-0000-20306 0 $1.00 $1.00 4/28/15 PAID BY METHOD.. RECEIPT.# CHECK # CLTD BY CONSTANCE KASHKAWOL CHECK R5539 255 MFA Total Paid forBUILDING STANDARDS ADMINISTRATION BSA $1.00 $1.00 `DESCRIPTION ACCOUNT.: CtTY ` , AMOUNT PAID PAID DATE WALL/FENCE - FIRST 100 LF 101-0000-42404 0 $47.86 $47.86 4/28/15 PAID BY: .: METHOD RECEIPT #• CHECK # CLTD BY CONSTANCE KASHKAWOL CHECK R5539 .255 MFA DESCRIPTION ACCOUNT QTY AMOUNT PAID. PAID DATE WALL/FENCE - FIRST 100 LF PC 101-0000-42600 0 $60.91 $60.91 4/28/15 PAID BY . METHOD. RECEIPT # _ CHECK #. CLTD BY CONSTANCE KASHKAWOL CHECK R5539 255 MFA Total Paid for FENCE OR FREESTANDING WALL- TOTALS:0• $108.77 $108.77 0• Description: KASHKAWOL RESIDENCE GARDEN WALL FINANCIAL NAME.TYPE NAME ADDRESSI CITY Type: WALL/FENCE Subtype: Status: ISSUED Applied: 4/28/2015 MFA Approved: 4/28/2015 MFA Parcel No: 643181018 Site Address: 46405 CAMEO PALMS DR LA QUINTA,CA 92253 Subdivision: TR 2043 Block: Lot: 16 Issued: 4/28/2015 MFA Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $1,500.00 Occupancy Type: Construction Type: Expired: 10/25/2015 MFA No. Buildings: 0 No. Stories: 0 No. Unites: 0 $1.00 Details: BSA: ADDITIONAL SITES LUNui (IONS CONTACTS FINANCIAL NAME.TYPE NAME ADDRESSI CITY STATE ZIP PHONE FAX EMAIL APPLICANT CONSTANCE KASHKAWOL 50325 VIA AMANTE LA QUINTA CA 92253 (760)989-1106 OWNER CONSTANCE KASHKAWOL 50325 VIA AMANTE LA QUINTA CA 92253 (760)989-1106 Printed: Tuesday, April 28, 2015 12:22:32 PM 1 of 2 Cff?m SYSTEti1S FINANCIAL INFORMATION 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 4/28/15 115539 255 CHECK CONSTANCE MFA • KASHKAWOL Total Paid forBUILDING STANDARDS ADMINISTRATION $1.00 $1.00 BSA: Printed: Tuesday, April 28, 2015 12:22:32 PM 1 of 2 Cff?m SYSTEti1S REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED STATUS REMARKS NOTES DATE BOND INFORMATION Printed: Tuesday, April 28, 2015 12:22:32 PM 2 of 2 CN? SYS TEti1S CLTD DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY NOTES BOND BEAM BLD FINAL" BY WALL/FENCE - FIRST FOOTINGS BLD CONSTANCE 101-0000-42404 0 $47.86 $47.86 4/28/15 R5539 255 CHECK MFA 100 LF KASHKAWOL WALL/FENCE - FIRST CONSTANCE 101-0000-42600 0 $60.91 $60.91 4/28/15 85539 255 CHECK MFA 100 LF PC KASHKAWOL Total Paid forFENCE OR FREESTANDING WALL $108.77 $108.77 TOTALS: $109.77 $1 nq 77 REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED STATUS REMARKS NOTES DATE BOND INFORMATION Printed: Tuesday, April 28, 2015 12:22:32 PM 2 of 2 CN? SYS TEti1S INSPECTIONS SEQID INSPECTION TYPE INSPECTOR SCHEDULED DATE COMPLETED DATE RESULT REMARKS NOTES BOND BEAM BLD FINAL" BLD FOOTINGS BLD REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED STATUS REMARKS NOTES DATE BOND INFORMATION Printed: Tuesday, April 28, 2015 12:22:32 PM 2 of 2 CN? SYS TEti1S Bin City of La Quinta. Building &r Safety Division P.O. Box 1504, 78-495 Calle Tampico. La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit !f Project Address: (ids' Q0 (/d ZIP Owner's Name: ��f A. P. Number: Address: ,gyp Legal Description: LeT ('Po B &Y/ 6,94� �z City, ST, Zip: 64 ao;L Contractor: Telephone: Address: Project Description: to szdc. G / City, ST, Zip: Telephone: �>:':�;;sv�� .?>:v`�H};. ' '.;.>:•;:;.:; • State Lic. 4: City Lic. M. Arch., Engr., Designer: Address: City., ST, Zip: Tel hone: eP .:}:>-:>;>a:. k:: £=r "<;�; ;; a° :...}»>, <; r'>.:>, -,-s';:.; •-4- :s<: s>}:...' : w _,. :y..........-r..:nom:} }.: w:.;.`ti�ww'v.": }:•'nv.t-i}r ".i:4}-LS:i-'`ihC'• Construction Type: Occupancy: State Lic. it: Project type (circle one): New Add'n Alter Repair Dorno Name, of Contact Person: I L&WJ9 Sq. FL :' ®� # Stories: Units: Telephone #,of Contact Person --o Estimated Value of Project: bo APPLICANT. DO NOT WRITE BELOW THIS LINE t/ Submittal Rcq'd Rec'd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Cates. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance. Title 24 Glu. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2°" Review, ready for corrcctionsfissue Electrical Subcontaetor List Called Contact Pcrson Plumbing Grant Deed Plans picked up S.M.I. proval Plans resubmitted Grading E:- tIN ''" Review, ready for eorrectionsfissue Developer Impact Fee pproval Called Contact Person A.I.P.P.. Appr Date of permit issue School Fccs " - - Total Permit tees P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT (760) 777-7012 FAX (760) 777-7011 Considering Becoming an Owner -Builder? 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 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 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 T -VY 4 4auhrw 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 buildingpermit has been submitted in your name listing yourself as the builder of the property improvements specified at ��i// e"9,Weo {��.s, LA 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. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each statement below to signs you understand or verify this information. 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. 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. ODA understand building permits are not required to be signed by property owners unless they are responsible for the /co�n�Istrruction and are not hiring a licensed Contractor to assume this responsibility. C�""�. 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. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. I understand if I employ or .otherwise engage any persons, other than California licensed Contractors, and the total value of in construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" er 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 government, 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. 6-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. &I 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. I&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.cslb.ca.gov for more information about licensed contractors. 0. I 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: Viw. 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 as well as employers. Aa,e n. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I 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 t agency is required a presented when the permit is issued to verify the property owner's signature. Signature of property owne Date: 1,.7�� 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 Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address:5 Name of Authorized Agent: �l��tii/�y Tel No Address of Authorized Agent: 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 accurac te: A copy of the owner's driver's license, form.notarization, or other verification acceptable to the agency is req red o be presented w t ermit is issued to verify the property owner's signature. Property Owner's Signa Existing Ilan 6raN:11B'•1'-0' 000O REVISIONS: WKG DWGS iDw •arU[KaDgMWWxDn w U.wa� �xD v/an ara"ntntp/vw>� anNiD rawevwu M oaWm"+� "nwa uiv Mrnuau tawn"a a/4w0. rY0 I I DESIGN LIMITE[ 1045 WYANDOTTE EAST WINDSOR: ONTARIO NSY,CS 510.012.0000 PROJECT NAME: CONNIE SANCTUARY DESIGNER: HARV/JC/LY/JL DRAWING NAME: DEMO PLAN SCALE: DATE: e"=1'-0" 04-21-15 SHEET NO.: -0113