BRER2019-001478-495 CALLE TAMPICO C& 0 U 4V Qai4a
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype: RE -ROOF/
Application Number: BRER2019-0014
Property Address: 51430 AVENIDA VILLA
APN: 773103004
Application Description: CLAVIJO / 2400SF REROOF WITH ASPHALT SHINGLE
Property Zoning:
Application Valuation: $4,000.00
Applicant:
VANESSA CLAVIJO
51430 AVENIDA VILLA FEB 0 8 2019
LA QUINTA, CA 92253
CITY OF IA QUINTA
DESIGN & DEVELOPMENT DEPARTMENT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 {commencing with Section 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 thA
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
4p mit subjects the applicant to a civil penalty of not more than five hundred dollars
[ 0 .:
as owner of the property, or my employees with wages as their sole
pensation, 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
col hi one year of completion, the owner -builder will have the burden of proving that
h r she did not build or improve for the purpose of sale.).
r' --
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
tf�ontractors' State License Law.).
am exempt under Sec. B.&P.C. for this reason
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 2/8/2019
Owner:
VANESSA & JAVIER CLAVIJO
51430 AVENIDA VILLA
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:
Carrie : Policy Number:
certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose
request and for whose benefit work is performed under or pursuant to any permit
issued as a result of this application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is
not commenced within 180 days from date of issuance of such permit, or cessation of
work for 180 days will subject permit to cancellation.
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 o enter up n the
above -mentioned property for inspection purposes.
Date/ v — i ure (Applicant or Agent): LL
Date: 2/0019
Application Number:
BRER2019-0014
Owner:
Property Address:
51430 AVENIDA VILLA
VANESSA & JAVIER CLAVIJO
APN:
773103004
51430 AVENIDA VILLA
Application Description:
CLAVIJO / 2400SF REROOF WITH ASPHALT SHINGLE
LA QUINTA, CA 92253
Property Zoning:
Application Valuation:
$4,000.00
Applicant: Contractor:
VANESSA CLAVIJO OWNER BUILDER
51430 AVENIDA VILLA
LA QUINTA, CA 92253
Llc. No.:
---------------------------------------------------------------------------------------------
Detail: REROOF ENTIRE ROOF WITH COOL ROOF SHINGLES [CRRC: 0890 0002] 2016 CALIFORNIA ENERGY CODE.
DESCRIPTION
BSAS SB1473 FEE
DESCRIPTION
RE -ROOF - EA ADDITIONAL 1,000 SF
DESCRIPTION
RE -ROOF - FIRST 21000 SF
DESCRIPTION
RE -ROOF - FIRST 2,000 SF PC
DESCRIPTION
TECHNOLOGY ENHANCEMENT FEE
ACCOUNT CITY
AMOUNT
101-0000-20306 0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:
$1.00
ACCOUNT QTY
AMOUNT
101-0000-42404 0
$12.81
ACCOUNT QTY
AMOUNT
101-0000-42404 10
$54.43
ACCOUNT CITY
AMOUNT
101-0000-42600 0
$108.87
Total Paid for RE -ROOF:
$176.11
ACCOUNT QTY
AMOUNT
502-0000-43611 0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE:
$5.00
PERMIT # ARC
Project Address:
APN #:
Applicant Name:
Address:
City, ST, Zip:
Telephone:
Email:
Contractor Name:
Address:
City, St, Zip
Telephone:
Email:
State Lic:
Arch/Eng Name:
Address:
City, St, Zip
Telephone:
Email:
State Lic:
gEmail:
rty Owner's Name:
s:
T, Zip ��
U1 1 I G
City Bus Lic:
City Bus Lic:
PLAN LOCATION:
Project Description: Pool, Remodel, Add't, Elect, Plumb, Mech
Valuation of Project $ L
New SFD Construction:
Conditioned Space
Garage
Patio/Porch
Fire Sprinklers
Construction Type:
Grading:
Bedrooms: j Stories:
SF
SF
SF
SF
Occupancy:
# Units:
New Commercial / Tenant Improvements:
a —Total Building SF
f r J_qConstruction Type; Occupancy:
- t Ct;4/
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CEC-CF1 R-ALT-05-E (Revised 04116)
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
rroject Name:
This compliance document is only applicable to simple c
with a HERS Provider Data Registry.
CALIFORNIA
MMISSIONO
CFIR-ALT-05-E
Page 1 of 3
mar ao not require HLHS verification for compliance. When HERS verification is required, a CF1R-ALT- 01 shall first be registered
Alterations to Space Conditioning Systems that are exempt from HERS verification requirements may use the CFIR-ALT-05 and CF2R- ALT-05 Compliance Documents. Possible exemptions from duct
leakage testing include: less than 40 ft of ducts were added or replaced; or the existing duct system was insulated with asbestos; or the existing duct system was previously tested and passed by a
HERS Rater. if space conditioning systems are altered and are Trot exempt from HERS verification, then a CFIR-ALT-02 must be completed and registered with o HERS Provider Data Registry.
Alterations that utilize close Cell Spray Polyurethane Foam (ccSPF) with a density of 1.5 to less than 2.5 pounds per cubic foot having an R-value other than 5.8 per inch, or Open Cell Spray
Polyurethane Foam (ocSPF) with a density of 0.4 to less than 1.5 pounds per cubic foot having an R-value of 3.6 per inch, shall complete and register a CFIR-ALT-01 with a HERS Provider Data
Registry.
If more than one person has responsibility for installation of the items on this certificate, each person shall prepare and sign a certificate applicable to the portion of construction for which they are
responsible. Alternatively, the person with chief responsibility for construction shall prepare and sign this certificate for the entire construction. All applicable Mandatory Measures shall be met.
Temporary labels shall not be removed before verification by the building inspector.
A. General Infornu-4on
01
Project Name:
j / ,
V 1
02
i
Date Prepared:
U
03
Project Location:
Y
VJ � a �d � �j l
VA L
Ij�
04
Building Front Orientation (deg or cardinal):
05
CA City:
{
u(
06
Number of Altered Dwelling Units:
07
Zip Code:
08
Fuel Type:
09
Climate Zone:
10
Total Conditioned Floor Area (ft):
S
11 Building Type: 12 Slab Area (ft) i r\
! V
13 Project Scope (Select all that apply):
B. Insulation ❑ D. & E. Fenestration/Glazing - ADD G. Space Conditioning System (Heating, Cooling, Duct system) Lighting
❑✓ C. Roof Replacement D D. & F. Fenestration/Glazing - REPLACE H. Water Heating System ❑ Include Mandatory Measures?
CA Building Energy Efficiency Standards - 2016 Residential Compliance April 2016
STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CALIFORNIA ENERGY COMMISSION
CEC-CF1 R-ALT-05-E Revised 04116)
CF1 05-E
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
Paggee 2 2 of 3
o
Dau Prcp7red:
Prgecl Namc:
C. Roof Replacement (Prescriptive Alteration, Section 150.2(b)1H)
pl 02 03 1 04 05 06 07 08 09 10
11 lz 13
Proposed
Minimum Required
R-value
Method of CRRC Product Product Deck Initial Solar Aged Solar Thermal SRI
Aged Solar Thermal SRI
Roof Pitch Exception ID Number Type Insulation Reflectance Reflectance I Emittance (Optional)
Reflectance Emiittance (Optional
((Compliance
VG��. �C. ��� 6`� 1 V
1C)
Add Row Delete Row
NOTES:
• Roof area covered by building integrated photovoltaic panels and solar thermal panels are exempt from the above Cool Roof requirements.
• Liquid field applied coatings must comply with installation criteria from Section 110.8(i)4.
CA Building Energy Efficiency Standards - 2016 Residential Compliance
April 2016
STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CERTIFICATE OF COMPLIANCE CF1R-ALT-05-E
Prescriptive Residential Alterations That Do Not Require HERS Field Verification Page 3 of 3
Project Name: Date Prepared-
49
-DOC- NlEWATION AUTHOR'S DECLARATION STATEMENT
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation utl�or Name: Doc mentativn Autpo�gnature:
�Lll
Company: V Signature Date:
�"IC1
Address- f �., _ ��V � C r � ( r j � CEA1 HERS Certification IdeRtificafion (!f applicable}:
CstylStatelLip: `j`•I� %J1/l.� 1�..{LCJ, IL 1 Phv
La GL)into- c, rgags��c�� C�-
RESPONSIBLE PERSON'S DECLARATION STATEMENT
I certify the following under penalty of perjury, under the laws of the State of California:
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 responsibility for the building design or system design identified on this Certificate of Compliance (responsible
designer).
3. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or system design identified on this Certificate of
Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations.
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents,
worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application.
5. 1 will ensure that a registered copy of this Certificate of Compliance shall be made available with the building permit(s) issued for the building, and made available to the enforcement agency
for all applicable inspections. I understand that a registered copy of this Certificate of Compliance is required to be included with the documentation the builder provides to the building
owner at occupancy -
Responsible Designer Name: Responsible Designer Signature:
Company : Date Signed:
Address: License:
City/State/Zip: Phone:
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300.
CA Building Energy Efficiency Standards - 2016 Residential Compliance
April 2016
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300.
CA Building Energy Efficiency Standards - 2016 Residential Compliance
April 2016
CITY OF LA QUINTA SUB -CONTRACTOR_ LIST
JOB ADDRESS PERMIT NUMBER OWNER - --BUILDER
This_forrn shall -be po,$,ted on the job with the Building Inspection Card at all times in a consl2icuous 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 resul, in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be compieted by applicant. "On File" is not an acceptable response.
Tiade 1 C.lassific.ation
God;rac;or
State Contractor's License.
Workers Compensation Insurance
City Business
License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EART:H.WORK I.C+1.2).:
CONCRETE (C-8)
FRAMING IC-5)
STRUCT. STEEL.(C=511:
:MASONRY (.C-29.)
PLUMBING (C-36)
LATH. PLASTER :(.C-3.5)
DRYWALL (C79:)
HVAC (C-201
ELECTRICAL (C-10)
::ROOFING IC<391
SHEET.METAL (C=::43)
FLOORING (C-15:).
GLAZING (C-17)
INSULATION (C=2)
SEWAGE DISP. (C-42)
PAINTING (C-33)
CERAMIC TILE (.C-54)
CABINETS (C=6)
FENCING (Ca13)
LAND:S.CAPIN&:(C=27 ).
POOL (C-53)
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
Owuer-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 Si nificant 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 fumncial
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 protectedfromthe 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 in
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-Buiider 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
Tibf 4 4 Q"
P.O. BOX 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760)777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IMPORTANT. NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at
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 farm 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
D RECTIONS: Read and initial each statement below to signer you understand or Vero this information:.
11. I understand a frequent practice of unlicensed persons is to have the property
building permit that erroneously implies that the property owner is providing his or her own laborr d matobtainerial pe on lly."Ownerui1, 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
ry property.
k. 1 understand building permits are not required to be signed by propertyowner
construction and are not hiring a licensed Contractor to assume this responsibility. s unless they are responsible for the
� b 3.1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may project
myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
wn.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California '
cnsed Conactors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials,I may beconsidered an "employer"
der state and federal law.
6. 1 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.
�7. I understand under California Contractors' State License l.aw, an Owner -Builder
structures cannot legally build them with the intent to offer them for sale, unless all hwork l�s performed lbyesidential 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
8I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
cial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
.�L9. 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 Califamia
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at I-
800-32 1 -CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
I-10. 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:
S�P1. I agree that, as the party legally a4d financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
4 t, 12. r agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the infornation 1
have provided on this farm. 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 darnages. If you obtain a permit as Owner -Builder and wish is 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 he agency is required to be presented when the permit is issued to verify the property
owner's signature. F ; _ 1� , 1
Signature of property owner Date:
Note: The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO CT ON PRO ERTY 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: