BRER2017-002878-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
BRER2017-0028
Property Address:
52293 EISENHOWER DR
APN:
773265013
Application Description:
FERGUSON / REROOF
Property Zoning:
Application Valuation:
$10,000.00
Applicant:
BRIAN FERGUSON
81162 FRED WARING DRIVE #104
INDIO, CA 92201
c&'�t 4 4 Qu&z
DESIGN & 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 for the
alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
s b'ects 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
com 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 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
ogsl}edid 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.).
(ohil am exempt under Sec. B.&P.C. for this reason
,Date: % 17 v 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 Na
Lender's Add
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner: .
BRIAN FERGUSON
81162 FRED WARING DRI E �n
INDIO, CA 92201
Contractor:
OWNER BUILDER
Lic. No.
Date: 3/3/2017
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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 37-00 of the Labor Code, for the performance
of the work for which this permit is issued.
I have and will maintain workers' :ompensation insurance, as required by
Section 3700 of the Labor Code, for the perfarmance of the work for which this permit is
issued. My workers' compensation insurance carrier and policy number are:
C• Policy Number:
_
yrrtify that in the performance d the work for which this permit is issued, I
shall not employ any person in any manner %o as to become subject to the workers'
compensation laws of California, and agree -.hat, if I should become subject to the
workers' compensation provisions of Section 3700 of the Lab 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 ($100,700). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKUOWLEDGEMENT
IMPORTANT: Application is hereby made tache 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 Cily 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
80 days will subject permit to cancellaton.
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-
mentioned property for inspection purpose!.
Date: 3-3-17Signature (Applicant or Agent):
Applicant:
BRIAN FERGUSON
81162 FRED WARING DRIVE #104
INDIO, CA 92201
Date: 3/3/2017
Owner-
BRIAN
wnerBRIAN FERGUSON
81162 FRED VvARING DRIVE #104
INDIO, CA 92201
Contractor:
OWNER BUILDER
Llc: No.:
--------------------------------------------------------------------------------------------
Detail: REROOF WITH GAF: TIMBERLINE HD SAGEWOOD TILE - MULTICOLOR [CRRC: 0676-0132] INSPECTOR MUST VERIFY R-38 INSULATION TO COMPLY
PER 2016 CALIFORNIA ENERGY CODE.
Application Number:
BRER2017-0028
Property Address:
52293 EISENHOWER DR
APN:
773265013
Application Description:
FERGUSON / REROOF
Property Zoning:
Application Valuation:
$10,000.00
Applicant:
BRIAN FERGUSON
81162 FRED WARING DRIVE #104
INDIO, CA 92201
Date: 3/3/2017
Owner-
BRIAN
wnerBRIAN FERGUSON
81162 FRED VvARING DRIVE #104
INDIO, CA 92201
Contractor:
OWNER BUILDER
Llc: No.:
--------------------------------------------------------------------------------------------
Detail: REROOF WITH GAF: TIMBERLINE HD SAGEWOOD TILE - MULTICOLOR [CRRC: 0676-0132] INSPECTOR MUST VERIFY R-38 INSULATION TO COMPLY
PER 2016 CALIFORNIA ENERGY CODE.
DESCRIPTION
ACCOUNT I QTY I AMOUNT
BSAS SB1473 FEE 101-0000-20306 1 0 $1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
RE -ROOF - FIRST 2,000 SF
101-0000-42404
0
$51.68
DESCRIPTION
ACCOUNT
QTY
AMOUNT
RE -ROOF - FIRST 2,000 SF PC
101-0000-42600
0
$103.36
Total Paid for RE -ROOF: $155.04
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
-r�
Bin # City of L Quinta
Buifding 8t Safety Division
Permit ;' 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-701,2 +
Building Permit Application and Tracking Sheet
- .i—oje'et AtlBress: .3 s e i1 v ` _o��"" a,pe flys 1 01 e e
A. P. Number:
Address:
Legal Description:
City, ST, Zip:L C a Z�
Contractor:
UiG �
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Tele o
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Address: g'` !� 2 j7—
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,- i ojecon:
City, ST, Zip:— U(p
_6 8
� Telephone:7b3
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State Lie. # :
City Lie. #.
-, 000 �7 tv G�
Arch., Engr., Designer:
S L9 61�
Address:
City, ST, Zip:
Telephone:
an cy:
Construction Type: Occupancy:
State Lie. #
cti7P �circleone}: New AddnrJAlter a
Demo
Name of Contact Person:
Sq. Ft.: l ('�
#Stories: or?
# Units:
O ne.
Telephone # of Contact Person:
stimated. Value=of�P_coj'ect:
APPLICANT: DO. NOT WRITE BELOW THIS LINE
>y
Submittal
Req'd
Rcc'd
TRACKING
PERMIT FEES
Plan Sets _
Plan Check submitted
Item
Amount
Structural Calc .
Reviewed, ready for corrections
^nClieckDepcsit
Truss Calcs.
Called Contact Person
Plan Check Balance.
Title 24 Calcs.
Plans picked up
Construction '
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd Revicw, ready for cor lions/issue
Electrical
SubcontactorListCall
ContactPcr n
Plumbing
Grant Dced
Plans picks
S.M.I. .
H.O.A. Approval
Plan esubmitted
Grading
IN 14OUSE:-
"'. Reyiew, ready.for correc s/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.T.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
T tal Permit Fecs
an
STATE OF CALIFORNIA
RESIDENTIAL ALTERATIONS
r:Fr:_CFi R_AI T_M_F lRevi—f fIR11d1
r.A1 IFr)R, IA INF:Pry r.r)MMISCIr)N
CERTIFICATE OF COMPLIANCE
:b::1H >'` � A
CF11R-ALT-01-E
Prescriptive Residential Alterations
02
(Page 1 of 4)
'P"r_oje'et N:a:me; 2, — / BVI p W CrUe Date Prepared:
Date Prepared:
06 , 4 *07 08 09
A. GENERAL INFORMATION
:b::1H >'` � A
01
02
Olde or Ject Name:---
02
Date Prepared:
06 , 4 *07 08 09
10
03r:jProject=location: yt ow of t
04
Building Front_drieriLation (deg or cardinal
:
Assembly Type
05=CA-City:— t yl
06
Number of *re! ed'Dwelling Units:
P4,81i�osed Ito,
Proposed
07 , =Zip-C-ode:�e
08
Fuel Type;.
Comments
flqCqntinuous
Cavity
R -value, _
09 crmate_Zone:'
10
1 Total�Con'd ti ned FlooraArea (ft2):
Table, Cell
11` —_Building Type
12
Slab Area(t2) f"V40
K ,
13y`ProjectScope:
_
5,f .
B. BUILDING INSULATION DETAILS (Section 150.2(b)1) _°
:b::1H >'` � A
01
02
03
04
05
06 , 4 *07 08 09
10
1K OZ' 08 09 10 11
11
Tag/ID
Assembly Type
Frame
Type
Frame
Depth
(inches)
Frame
Spacing
(inches)
P4,81i�osed Ito,
Proposed
Required
Required
Initial Solar Aged Solar Thermal SRI Aged SolarThermal
Reflectance Reflectlance Emittan/}c/e (Optional) Reffllec
Comments
flqCqntinuous
Cavity
R -value, _
Insulation
R -value ; U,fRotor
4Appendix 1A4
Reference
U -Factor
Table, Cell
AA
ZAK
K ,
1K. 0, ,
R
NOTES%�
• Koof area covered by bulldin''?Iniegrated ph'otovblic' anels and solar they'° al panels are exempt from the above Looi Koof requirements.
• . Liquid field appliedoatngs must comply wi hllnstallation criteria from section 110.8(i)4.
a
") V —& 1 -1
rC==R-GO.'F:REPLACEMENT.(:P_rescrip.tive>Altera.ti'on, Sey..7ctikon�1}50'2
:b::1H >'` � A
Ol
02
03
04 yl
05 "
06
1K OZ' 08 09 10 11
13
Method of
Co'm'pliant
Roof
Pitch
Exception
CRRCProduct ID
ber ,
-
# Pr>opductType .,
R -value -jyx
D , k
i��;y^s'ulati:on
Proposed
Minimum
Required
Initial Solar Aged Solar Thermal SRI Aged SolarThermal
Reflectance Reflectlance Emittan/}c/e (Optional) Reffllec
ant
SRI
Emittance (Optional)
{q)/p��rtn
76'-1113 2
aqbe
AA
ZAK
NOTES%�
• Koof area covered by bulldin''?Iniegrated ph'otovblic' anels and solar they'° al panels are exempt from the above Looi Koof requirements.
• . Liquid field appliedoatngs must comply wi hllnstallation criteria from section 110.8(i)4.
Registration Number: Registration Date/Time:
CA Building Energy Efficiency Standards - 2013 Residential Compliance
H RS rovider:
June 2014
STATE OF CALIFORNIA
RESIDENTIAL ALTERATIONS
CEC-CFIR-ALT-01-E Revised 06/14
CALIFOR 41A E NERGY COMMISSION,
CERTIFICATE OF COMPLIANCE
CF1R-ALT-01-E
Prescriptive Residential Alterations
(Page 4 of 4)
Project Name: I Date Prepared:
Document i n Author Signature:
1�j
4N
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
1. 1 certify that this Certificate of Cc liance documentation is accurate and complete.
Documentation A or Name: /^
Document i n Author Signature:
V
Company:
Signature ate:
Address:
CEA/ HERS Certification Identi .catlbr�(if applicable):
City/State/Zip:
2--- 21,49
Phone:
RESPONSIBLE PERSON'S DECLARATION 9TATEMENT
I certify the following under penalty of perjury, under the laws of the State of California 0.,
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responsib�il. Y -for the building 'des igffior system design identified on this Certificate
designer).
of
ompliance (responsible
3. That the energy features and performance specifications, materials, components, and manufactured d`ees,for the building design or system design identifiedon
w ` o
his Certificate of
�
Compliance conform to the requirements of Title 24, Part 1 and Part 6 othe California Code of, Rtaldtions.
documents,
4. The building design features or system design features identified on this Certificate of Commplliiaance=are consiis�te�n�t;wif wtlie.information provided on other applicable
compliance
worksheets, calculations, plans and specifications submitted to the enforcement agency fdrapproval with this building permit application.
5. 1 will ensure that a registered copy of this Certificate of Complignrce<sl all be made..availyable with the building permlt(s) issued far the building; and made availa
Y�3
Compliance builder
let
the enforcement agency
building
for all applicable inspections. I understand that a registered copy of this Certificate`of Is red'to be included with the documentation the
provides
to the
owner at occupancy.'
Responsi Designer Name: c u `` . �
wRespon.' Designer Signature:
Company. r ° �
Date Signed: Gh
t/
Address: f
License:
City/State/Zip:
Phone:
For assistance or questions regarding.the Energy Standards, contact the Energy Hotline at: 1-800-772-3300.
Registration Number: Registration Date/Time: HRS �rovlcler:
CA Building Energy Efficiency Standards - 2013 Residential Compliance June 2014
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING 8t. 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
riskrisk 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_y_our_own General_Contracicr,_the-pemut-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 Siiznificant 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, perfotmance, safety and welfare while on your property. WARNING: Cost savings benefit csn.tumlo 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 ensue 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 liabiliaies
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 repleced.
■ 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 defendaritin 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, yo -i must register with
the-state-and-federal-government=withhold-payroll-taxes–provide-workers compensa ion -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 CONSIDERTHE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR .
YOUR CONSTRUCTION PERMIT .
Taf 414Quh -4
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 imit has been subs d ' your name listing y�rrself as the builder of the property
improvements specified at
ei
Weare providing you with an Owner -Builder Acknowledgment and Iii0iiiation Verifica on Form to =Make you of�/
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 signer you understand or verify this information.
I understand a' frequent practice of unlicensed persons is to have the property owner obtanl 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
015--1
%o�n mproperty.
/� 2. I understand building permits are not required to be signed by property owners unless they are responsible for
construction and are not hiring a licensed Contractor to assume this responsibility. P the
3. I understand as an "Owner-Builder"'I am the responsible party of record on the permit I understand that I may protect
r-
myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own. _ .
4. I understand Contractors are required by law to be licensed and bonded in California and to list tLeir license numbers on
permits and contracts.
U-75. I understand if I employ or otherwise engage any persons, other than California licensed Contraciors, 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 tate and federal law.
I understand if I am considered an "employer" -�- mployer 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
compensa 'wn for each "employee." I also understand my failure to abide by these laws may subject ne to.serious financial
7. I understand under Calif C
omra ontractors 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 nof exceed four within any. calendar year, or all of the work is performed
under contract with a licensed general building. Contractor.
-722S-?
n 8. I undo .
rstand 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 con-truction defects in the
wnship or materials.
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-
8 0-1-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 E
party legally: and fi cially espo ible #or proposed c nstruc on activity at the. follo ng address:
��r 4-ot Q L,24, kf2;" , c2 217 5
/ l
I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
a p cabWaws and requirements that govern Owner -Builders as.well as employers.
112. 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 requir to be presented when the permit is issued'to verify the property
owner's signature.
Signature of property owner �}
Note: The following Authorization Form is required to be completed by the property owner otr'y 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: 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 persona ly filled out the above
information and certify its accuracy. Note: A copy of the.owner's driver's license, form notarization, or imher verification
acceptable to the agency is required to bepresented when thepermit is issued to verify thepropertyowner s signature.
Property Owner's Signature: Date: