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BWFE2018-02084o 78-495 CALLE IAMPICO � 0 D Qa&&� LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT Permit Type/Subtype: WALL/FENCE/CITYSTANDARD/PRE-APPROVE D Application Number: BWFE2018-0208 Property Address: 51540 AVENIDA ALVARADO APN: 773123002 Application Description: MARTIN / 185LF GARDEN AND WALLS AT FRONT COURTYARD Property Zoning: Application Valuation: $5,000.00 Applicant: n Lr MARTIN, TIFFANY jJ 51540 AVENIDA ALVARADO � � 2�18 LA QUINTA, CA 92253 U 017 M_WZ_1I IN�EHTI pEPAFfTMfl�f LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 fcommencing with Section 70001 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 subjects the applicant to a civil penalty of not more than five hundred dollars V.p . sowner of the property, or my employees with wages as their sole ensation, will do the work, and the structure Is not intended or offered for sale. (Sec7044, Business and Professions Code: The Contractors' State License taw 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 a e year of completion, the owner -builder wIII have the burden of proving that r id not buitd or improve for the purpose of sale.). 1 s ner of the property, am exclusively contracting with licensed contractors to construct the project. (Sec. 7044, Business and Professions Code: The Con traCtors` 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.). () I am exempt under Sec. B.&P.C. for this reason Date: ' i 1 Owner• � A i AfAAA 4� A-,- CONSTRUCTION LENDI G GE 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 Lender's VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 9/27/2018 Owner: MARTIN, TIFFANY 51540 AVENIDA ALVARADO LA QUINTA, CA 92253 Contractor: OWNER BUILDER Llc. No.: 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: Car Policy Number: I certify that in the performance of the work for which this permit is issued, I shal a e ploy 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: ` Applican . WARNING: FAILURE TO SECURE WORKERS'COMP NSATION C VERA f 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. 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 representativ above -mentioned property for inspection purpos, Date: 9 )-14 Signature (Applicant or Date: 9/27/2018 Application Number: BWFE2018-0208 Property Address: 51540 AVENIDA ALVARADO APN: 773123002 Application Description: MARTIN / 185LF GARDEN AND WALLS AT FRONT COURTYARD Property Zoning: Application Valuation: $5,000.00 Applicant: MARTIN, TIFFANY 51540 AVENIDA ALVARADO LA QUINTA, CA 92253 Owner: MARTIN, TIFFANY 51540 AVENIDA ALVARADO LA QUINTA, CA 92253 Contractor: OWNER BUILDER Llc. No.: Detail: 85LF OF 6' GARDEN WALL AT NORTH, EAST AND SOUTH PROPERTY LINES AT COURTYARD. [CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. THE AREA BETWEEN THE BACK OF CURB AND ANY FENCING SHALL BE LANDSCAPED, HAVE A SUITABLE PERMANENT IRRIGATION SYSTEM, AND BE CONTINUOUSLY MAINTAINED BY THE PROPERTY OWNER. 2016 CALIFORNIA BUILDING CODES. ta Qaiata PERMIT # 2,Q ( 8 4- V 2ro L PLAN LOCATION: Project Address: rim o Project Description: Pool, Remodel, Add't, Elect, Plumb, Mech APN #: I ` `-77� Applicant Name:—T, Address:5i City, ST, Zip: A �aa5 3 Telephone: D5- -bG -T _ 4 L/ b Email: ' (xV\ , rt: v�d Va luation of Project 5 i I C Arch/Eng Name: Construction Type: Occupancy: Address: Grading: City, St, Zip Telephone: Bedrooms: Stories: # Units: Email: State Lic: City Bus Lic: Property Owner's Name: -r,- `} New Commercial / Tenant Improvements: Address: 5 Total Building SF City, ST, Zip L Construction Type: Occupancy: Telephone: _ y_ Email: , '1 i 78495 CALLE TAMPICO � A5 LA QU I NTA, CA 92253 760-777-7000 DG r t5 .G OFFICE USE ONLY # Submittal Req'd Rec'd Plan Sets Structural Calcs Truss Calcs Title 24 Calcs Soils Report Grading Plan (PM10) Landscape Plan Subcontractor List Grant Deed HOA Approval School Fees Burrtec Debris Plan Planning approval Public Works approval Fire approval City Business License INFORMATION DESCRIPTION ACCOUNT CITY AMOUNT WALL/FENCE - FIRST 100 LF 101-0000-42404 0 $52.01 DESCRIPTION ACCOUNT CITY AMOUNT WALL/FENCE - FIRST 100 LF PC 101-0000-42600 0 $65.02 Total Paid for BLOCK WALL: $117.03 DESCRIPTION ACCOUNT CITY AMOUNT BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT CITY AMOUNT RECORDS MANAGEMENT FEE 101-0000-42416 0 $10.00 I Total Paid for RECORDS MANAGEMENT FEE: $10.00 DESCRIPTION IACCOUNT I CITY I AMOUNT I TECHNOLOGY ENHANCEMENT FEE 1502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 CITY OF LA QUINTA SUB -CONTRACTOR. LIST JOB ADDRESS 515-NO N vD. RWWAV-ATJ6 PERMIT NUMBER�&,�yi=ezg -o zoo OWNER T! FI-ABC M( I� _ -BUILDER OW6-IF-w— 7t-"itLbEK This form shall be posted on the mob with the Building Inspection Card at all times in a conspicuous place, Only persons appearing on this list or their employees are authorized to work on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance „f t..;l,ai- .,ormi+ r:— — k onnli�nkla trarip all infnrmntinn rprfllpCtprl hpin\N mimt hp cmmniptp.ri by annlicant_ "(fin File" is not an acceptable response. .... ..... ... ...... .. Trade I Classification - ...:......... ............. .. . ............... Cvntractar ... ..., .. ..... ...::...., ... State C.ontract:or:'s--License „ •.._ -. ....... ... _. _ . .. .. .. ...... ... ;... :..... ....,.:; ... ........ ........ ...... .. .. ......... _. Workers Co..mp.ensation 1.tlsurani~e City 8us�ne.gs Li cerise Company Name Classification (e.g. A, B, C-8) License Number (xxxxxx) Exp. Date (xx/Ax/xx) Carrier Name Policy Number Exp. Date License Number Exp. Date (e.g. State Fund, CalComp) (Format Varies) (xx/xx/xx) (xxxx) (xx/xx/xx) EARTHWORK (C-t 21 CONCRETE (C-8) _ FRAMURG: (0-5) .. STRUCT. STEEL .(C-5.1-) .. MASONRY (C 29) owl? 3iutLpE� � 3 H PLUMBIN:6 (C-36) A �Q►Ic�1D CoN�trc7Z f�pT LATH, PLASTER. -DRYWALL (C=9) _. HVAC (C720). EL> CTRICAL (C-10) f ROOFING (C-39.) SHEFF METAL (C-43) FLOORING (C-15) GLAZING (C-17) -INSULATION (C-2) SEWAGE D1SP. (:C-42) PAINT N.G [.C-33). CERAMIC TILE: (C-54) CABINETS (C-6) FENCING (C.-13) LAND:SCAPIN3:(C-27) :POOL (C-5.3) h i HEIGHT FROM TOP OF FOOTING I 1 � z 12" 10" R EV ERSI"_ DIRECTION 01- HOOK ON EVERY OTHER RE(?AR 4 HO. ZCNTAL REBAR (USE POND 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 �4_ W" _ __ I (FOOTING WIDTH) SEE TABLE "A" TABLE "A" VERTICAL REINFORCEMENT 3' 17" #4 @ 48" O.C. 4' 20'' #4 @ 48" O.C. 5' 23" #4 @ 48" O.C. 6' 29" #4 @ 241" O.C. NOTES: I I H" HEiGH'f FROMTOP OF FOOTING 1 SEE TABLE "B" FOR REBAR SIZE — AND SPACING (I.C;; A'f M. R'LA. AN IN (;4N 1".P Ui' CC.ij ) FINISH GRADE (1) - #4 REBAR (2) - #.4 REBAF CONTINUOUS ALL F'00I-INGS ADJACENT TO SLOPES TO BE AT LEAST 5' TO DAYLIGHT AS SHOWN BELOW, a Elol7Ona Jr�'fi I- o` J Mlr r• oorrnlc 1) THIS DESIGN DOES NOT ALLOW GRADE DIFFERENTIALS OF MORE THAN 6" ON OPPOSING SIDES OF THE WALL. THIS IS NOT A RETAINING WALL. 2) FENCE HEIGHTS ARE REGULATED -- CONSULT ZONING REGULATIONS BEFORE BEGINNING CONSTRUCTION. 3) NO WATER COURSE OR NATURAL DRAINAGE SHALL BE OBSTRUCTED. 4) GROUT ONLYTHE CELLS CONTAINING REBAR. THIS WALL 1S NOT DESIGNED FOR ALL CELLS TO BE GROUTED, 5) ALL REBAR TO BE ASTM SPEC. A61 5, GRADE 40 MINIMUM. 6) ALL REBAR LAP SPLICES TO BE 2411 MINIMUM. 7) ALL MASONRY UNITS TO BE ASTM C-90 GRADE N. 8) REBAR TO BE CENTERED IN MASONRY CELLS. 'SEE PAGE 2 FOR ADDITIONAL INFORMATION` DISCLAIMER: ALTERNATE DESIGNS MAY BE POSSIBLE WHEN PROVIDED WITH AN ENGINEERED ANALYSIS. USE OF THIS STANDARD DESIGN IS AT THE USER'S RISK AND CARRIES NO IMPLIED OR INFERRED GUARANTEE AGAINST FAILURE OR DEFECTS. r I�Illl !(FOOTING WIDTH)! SEE TABLE "B" TA13LE ".B" „H�• ,. ..WREINFORCEMENT VERTICAL 3' 1 9" #4 @ 48" O.C. 4' 22" #4 @ 48'—'O.C.' 5' 29" #4 @ 48" O.C. 6' 34'' #4 @ 24'' O.C. CHECK'vVITH THE, BUILDING DEPARTMENT TO VERIFY IF A BUILDING PIERMLT IS REQUIRED. WHEN A PERMIT IS REQUIRED, THE FOLLOWING INSPECTIONS ARE REQUIRED: 1) FOOTING; EXCAVATION TRENCH CLEAN WITH STEEL IN PLACE AND SUPPORTED 3" ABOVE AND AWAY FROM THE SURROUNDING EARTH/DIRT. 2) REBAR/PRE-GROUT: BOND BEAM REBAR AND VERTICAL REBAR IN PLACE- INSPECTION PRIOR TO PLACING GROUT. 3) FINAL; AFTER GROUT IS PLACED - PRIOR TO ANY DECORATIVE CAP PLACEMENT. WESTERP4 RIVERS1015 COUNTY CODE UNIFORMITY PROGRAM a 4"yc- FREESTANDING BLOCK WALL PIIONr (760) 777-712:I 7,)A95C'ALL)r!,TAMPICO I A oUIN11A, C:AIJV014N[A 9225:3 FAX (760) 777-701 1 1(!/)/2U1 1 UIifT. PACE 1 Oil FO( DESIGN PARAMETERS: ACTIVE SOIL PRESSURE (PSF) = 30 PASSIVE SOIL BEARING (PSF) = 1 50 COEFFICIENT OF FRICTION = 0.25 ALLOWABLE SOIL BEARING (PSF) =1 500 WIND = 80 MPH. EXPOSURE C SEISMIC: NA= 1.3. Nv= 1.6. Z=0.4, SOIL PROFILE=SD WESTERN RIVERSIbE COUNTY CODE UNIFORMITY PROGRAM Ci FE FREESTANDING BLOCK WALL P[10NL (7GU) 777-77 25 78-4195 CALLA TAMPICO LA QUINTA, C7AI.IFORT11TA 92253 I,AX (760) 777-7011 10101<014 cntilnaur;rrruew;i ass[?tom of i�. iAc77,2011'1) Tw�l 4 4aw BUILDING & SAFETY DEPARTMENT 78-495 CALLS TAMPICO (760) 777-7012 LA QUINTA, CALIFORNIA 92253 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: Ili 91rhest 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 Sienifcant 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 10 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 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 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 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 buildin permit has =e=muhnu ed in Qvr4 name listing,yourself as the builder of the property improvements specified at �� 1 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 signer you understand or verify this information. I understan d a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" "buildi g permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. I understand building permits are not required to be signed by property owners unless they are responsible for the co ction and are not hiring a licensed Contractor to assume this responsibility. . I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect awn. from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on and contracts. my I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value nstruction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. *compensation nderstand if I am considered an "employer" under state and federal law, I must register with the state and federal t withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment for each "employee." I also understand my failure to abide by these laws may subject me to serious financial r' I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential to s 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. T understand as an Owner -Builder if I sell the roe for which this property rty 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 w knzanship or materials. . 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. 'IL4. 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: I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applie le laws and requirements that govern Owner -Builders as.well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I L'velprovided 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. Signature of property owner _ j J I Date: Note_ The following Authorization Form is required to be completed by the property owner only when designating an agent of the properly 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 owner's signature. Property Owner's Signature: Date: +l zi c CD FI OF N 0 d V cr y 0 (f}_ m r j- 0 0 -,to < 0 0 o m �� IW< T.OmO m orn cl MOZ 64 041