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11-1209 (AR)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number:1.1JOODOfi2"0"9� I hereby affirm under penalty of perjury one of the following declarations: Property Address: 79612 .MISSION DR ' E APN: 649-650-010- - - Application description: ADDITION - RESIDENTIAL Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 7975 i • e ulk 14 ^� VOICE (760) 777-7012- -I FAX (760) 777-7011 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT 11111 te* 1/0/12 Owner: SANDRA LUSCOMBE 79612 MISSION ;DRIVE EAST U f�A� LA QUINTA, J CA 92253 . 0 1CITV201 a a A UIN7A Contractor: Applicant: Architect or Engineer. Owner LQPERMIT LICENSED CONTRACTOR'S DECLARATION ,. .. - WORKER'S COMPENSATION DECLARATION hereby -affirm under penalty of perjury that I am.licensed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations: 'Section 7000)of Division 3 of the Business and Professionals Code, and my License is in full force and effect. _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided ' • License Class: License No.: for by Section 3700 of the Labor Code, for the performance of the work for which this permit is - ` issued. Date: Contractor: _ 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 • OWNER -BUILDER DECLARATION - insurance carrier and policy number are: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the Carrier - - Policy Number following reason (Sec. 7031.5, Business and Professions Code: Any city or county that -requires a permit to 1l I certify that, in the performance of the work for which this permit is issued, I shall not employ any - construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the 7"1 person in any manner so as to become subject to the workers' compensation. laws of California, permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State _ and agree that, if I should become subject tothe workers' compensation provisions of Section - License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 3700 of the Labor Code, I shall forthwith c ply with those provisions. • 1 that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by - for five hundred dollars i _ .,A 1 _..w 1_ ' Qr1*pplicant: YW�� an pplicant a permit subjects the applicant to a civil penalty of not more than ($500).: (_) 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and ate: the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: -The - WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL Contractors' State License Law does not apply to an owner of property who builds or improves thereon, . SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND and who does the work himself or herself through his or her own employees, provided that the DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN improvements are not intended or offered for sale. If, however, the building or improvement is sold within SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. 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.).. - APPLICANT ACKNOWLEDGEMENT 1 _ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the - 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of conditions and restrictions set forth on this application: property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed 1. Each person upon whose behalf this application is made, each person at whose request and for pursuant to the Contractors' State License Law.). whose benefit work is performed under or pursuant to any permit issued as a result of this application, (_) I am.exempt under Sec. ,.B.&P.C. for this reason 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 ' XDate: ' pperformed I 2-0wner: -ANN2. under or following issuance of this permit. - 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 CONSTRUCTION LENDING AGENCY permit to cancellation. I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the I certify that I have read this application and state that the above information is correct. I agree to comply with all work for which this permit is issued (Sec. 3097, Civ. C.)• - city and county ordinances and state laws relating to building construction, and hereby authorize representatives ' - Lender's Name: of this cm4itV tolenter upon the above-mentioned property for inspection purpo s. ate: Signature (Applicant or Agent): . Lender's Address: - - LQPERMIT Application Number . . . 11-00001209 ------ Structure Information 74SF ADD W/150SF PATIO/VB/RES-3 [ENG], ----- Other struct info . . . . . CODE EDITION 2010 # BEDROOMS 1.00 FLOOD ZONE NO PATIO SQ FTG 150.00 1ST FLOOR SQUARE FOOTAGE 74.00 Permit BUILDING PERMIT Additional desc . Permit Fee 99.00 1 Plan Check Fee 64.35 Issue Date Valuation 7975 Expiration Date 7/03/12 Qty Unit Charge Per Extension BASE FEE 45.00 6.00 9.0000 THOU .BLDG 2,001=25,000 ---------------------- 54.00 Permit ELECT --ADD/ALT/REM Additional desc . Permit Fee .' 17.59 Plan Check Fee 4.40 Issue Date Valuation. 0 Expiration.Date 7/03/12-• Qty Unit Charge Per Extension BASE FEE 15.00' 74.00 .0350 ELEC NEW RES = 1 OR 2 FAMILY .2.59 Special Notes and Comments _"74SF ADDITION TO MASTER BEDROOM WITH 150SF PATIO ADDITION/VB/RES-3/CLASS A -FR [ENGINEERED] THIS PERMIT DOES NOT INCLUDE ALTERATIONS TO THE EXISTING PATIO COVER OR FAMILY ROOM. 2010. CALIFORNIA BUILDING CODES. January 5, 2012 4:44:33 PM AORTEGA ----------------- ---------------------------------------------------------- Other Fees BLDG STDS ADMIN (SB1473) 1.00 ENERGY REVIEW FEE 6.44 STRONG MOTION (SMI) - RES. .80 Fee summary Charged Paid. Credited Due Permit Fee Total 116.59 .00 .00 116.59 Plan Check Total 68.75 .00 .00 68.75 Other Fee Total 8.24 .00 .00 8.24 LQPERMIT .. _ LQPERMIT . Bin # Permit # / �oq Project Address: A. P. Number: Legal Description: Contractor: 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 Owner's Name: S -S co (n C t—_— E Address: 12- 11)15S r4 b j�,7 I:--- City, ST, Zip: 14 61 � 114 771 ft- 0 2- 3 rn NTA0,7r --L* Telephone: Address: Project Description: City, ST, Zip: exie rk NJ V1 Telephone: State Lic. 9 City Lic. C00Y �,A/I(k(A Arch) Engr., Designer: NE j_ S,0 E 5 ic—ITI(S Address: I�Wc) 1515VYOU co 0 CIL T- City, ST, Zip: CA 92-3o7 Telephone: '(60- 3 4' S Construction Type: Occupancy: ' 0 ------- ......... State Lic. Project type (circle one): New Add'n Alter Repair Demo Name of Contact Person: f —7rJnits: Sq. Ft.: # Stories: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE N Submittal Req'd Rec'd TRACKING PERMIT FEES Plan Sets iPlan Check submitted Item Amount Structural Caics. Reviewed, ready for corrections y tI Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Title 24 Cales. Plans picked up Construction Flood plain plan Plans resubmitted 11Mechanical Grading plan 2'! Review, �readyr on srissue Electrical Subcontactor List Called Contact Pcrson-- Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- Review, ready for correcfioxa-�Z- Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees is MW 7 11 i 11mls-lott - Msls-m Vf.(- )Z16 gslax MorJOVASLZ to wft& fee? (0&r9%*Cr"L %OVO CERTIFICATE OF COMPLIANCE Desert Sands Unified School District q���y1FtE27rra 47950 Dune Palms Road 13ERMUDAOUNES Date 1/9/12 La Quinta, CA 92253 RANCHO MIRAGE r INDIANwEus No. 31187 (760) 77't-$515 PALM DESERT s oIND OTy� Owner Sandra Luscombe APN # 649-650-010 Address 79612 Mission Drive East Jurisdiction La Quinta City La Quinta Zip Permit # Tract # No. of Units 1 Type Residential Addition Lot # No. Street S.F. Lot # No. Street S.F. Unit 1 79612 Mission Drive East 74 Unit 6 Unit 2 Unit 7 Unit 3 Unit 8 Unit 4 Unit 9 Unit 5 Unit 10 Comments At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile homes. It has been determined that the above -named owner is exempt from paying school fees at this time due to the following reason: Residential Addition 500 Sq Feet or Less EXEMPT This certifies that school facility fees imposed pursuant to Education Code Section 17620 and Goverment Code 65995 Et Seq. in the amount of $0.00 X 74 S.F. or $0.00 have been paid for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. Fees Paid By Exempt - Sandra Luscombe Name on the check By Dr. Sharon P. McGehee Superintendent Check No. Telephone Funding Exempt Fee collected lexemp �d by Sharon McC`ilvr y Payment Recd 50.00 Over/Under Signature NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve. to notify you that the 90-day approval period in which you may protest the fees or other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier. NOTICE: This Document NOT VALID without embossed seal Embossed Original - Building Department Applicant Copy - Applicant/Receipt Copy - Accounting Merrellohnson Cohe;l'1iJEE.S. BRC Construction Attn: Brandon Rickard brcframing@aol.com (760) 277-8925 Re: Luscombe Addition 79-612 E. Mission Drive La Quinta, CA 92253 MJE Job No. 2575-45 Dear Brandon: February 23, 2012 We have reviewed the concern with the location of the existing beam at the Master Suite addition. It is our understanding that this beam was originally located at the center of the exterior column. A new wall was to be constructed with the existing beam left in place. However the proposed plans show the wall in line with the exterior wall of the Family Room. We feel that this issue can be corrected by framing a new wall as shown on the plans. Therefore the existing 6x8 beam will not remain in place as noted on the plans. We also believe the support of the existing trusses to be adequate with this adjustment of their bearing location, This determination is based on information you provided regarding the truss construction. Please let us know if we can be of further assistance - Sincerely, Merrell -Johnson Engineering, Inc. Michael E. Casady, P.E. Associate Engineer ENGINEERING I SURVEYING I TESTING I INSPECTION 22221 US Highway 18 Apple Valley, CA 92307 f, 7, 6 ?-2 40-8000 0 760-240-1400 w) www.merrelljohnson.com Prescriptive Certificate of Compliance: CF-1R ADD Residential Additions (Page 1 of 5 Site Address: Enforcement Agency: Date: 79-612 E. Mission Dr., La Quinta CA October 25, 2011 General Information Project Name Luscombe 74 s.f. Addition Climate Zone # 15 # of Stories 1 Building Type❑x Single Family Q Multi Family Circle the Front Orientation N, E, S, W or Degrees South Conditioned Floor Area of Addition [New (CIA): 74 Addition Size: x Less than or equal to 100 fe ElLess than or equal to 1000 fe (Do not use this onn or additions eater than 1000 ,2) NOTE: For Afferadow to an ending home, submit a congtleted CF-IR ALT Form Exce : 1p!*tirr MAC. ems that are rephwedoF offered to serm the addhion nsay be included on the CF-IR ADD Form PRESCRIPTIVE ENVELOPE REQUIREMENTS FOR ADDITIONS For standard wood and assemblies incefigg the Cavity R-value onl '. • For 100 ft1 additions; the Proposed values must be equal or greater than the Standard column or when indicated when using Package D, "Pkg D ". Enter values in the shaded Proposed Columns • For less than 1, 000ftzadditions must comply with "Pkg D"requirements unless indicated in the Standard Column_ To meet `PkgD"minimum energy compliance re, ruirements, see RCMAppendix B, Table I51-C or $152(b) in the RCM_ Enter values in the shaded Proposed Columns. Size of Addition 100 fe or less Less than. 1,000 fe Component Standard Proposed Comment Standard Proposed Continent Ceiling Insulation R-19 Minimum Pkg D R-38 Table 151-C Wall Insulation R-13 Minimum R-13 R-13 Minimum Floor Insulation R 13 Minimum Pkg D n/a Table 151-C Fenestration U- factor SHGC U- factor SHGC �'� From `Fenestration Proposed Areas" Page t of 5 U- factor SHGC U- factor SHGC Enter Values From "Fenestration Proposed Areas ' Page 2 of 5 0.40 Pkg D 0.40 Pkg D .40 .35 Maximum Glaztng Area 50 W 1{z t Addition Alone 83. Q v v � Enter Values From Addition Allowed Fenestration Areas" Page 3 of 5 ForWest-Facing Orientation2� 3.7 Radiant Barrier N/A Pkg D Table 151-C Roofing N/A See Roofing Products Below Pkg D See Roofing Products Below OPAQUE SURFACE DETAILS For the furred portioned of Mass walls see Furring Strips Construction Table below. A B C D E F G I H I J Proposed S° Note Standard Values From JA4 Table Tag/ IDl Assembly Name or Type2 Framing Material and Size2 Thickness, Spacing, or Othero U- factor' JA4 Table Numbers Framed Cavity R value6 Continuous Insulation R-Values JA4 Assembly Cell Value' Proposed Assembly U-factor' Roof Wood/Truss 24" .026 4.2.1 38 0 A _026 Wall Wood/2x4 16" _102 4.3.1 13 0 A .102 11'1 C' L Note: For furred assemblies, accaj nfing_f(DRn04D"eTZfqU- ew F&We J,4 Furrxng Construction table below 3 and Equation 4-L For culruluwalls use the Mass and DATE i BY RECEIVED Registration Number_ Registration Date17-Ime.- 2008 Residential Compliance Forms HEEFY order_ March 2010 Prescriptive Certificate of Compliance: CF-1R ADD Residential Additions (Page 2 of 5 Site Address: Enforcement Agency: Date: 79-612 E. Mission Dr., La Quinta CA October 25, 2011 1. For Tag/ID indicate the identification name that matches the building plans. 2. Indicate the Assembly Name or type: Roaf/Ceiling, Walls, Floors, Slabs, Crawl Space, Doors and etc --- Indicate in column G the Frame material and Size: For Wood, Metal, Metal Buildings, Mass, enter 2x4, 2x6, or etc_ _ _ see JA4 for other possible frame type assemblies_ 3. Enter the thickness for mass in inches or Spacing between framing members enter, 16' or 24 "OC, or Other for all other assembly description such as Concrete Sandwich Panel, Spandrel Panel, Logs, Straw Bale Panel, and etc_... 4. Based on the Climate Zone, enter the equivalent Ufactor found in JA4 Table based on the R-Value from Table 151-C 5. Enter the Table number that closely resembles the proposed assembly. 6. Enter the R-value that is being installed in the wall cavity or between the framing; otherwise, enter " 0 ". 7. Enter the Continuous Insulation R-value for the proposed assembly, otherwise, enter -0 "_ 8. Enter the row and column of the U factor value based on Column F Table Number and enter the Assembly Ufactor in Column J 9. The Proposed Assembly Ufactor, Column J, must be equal to or less than the Standard Ufactor in Column E to comply - FURRING STRIPS CONSTRUCTION TABLE FOR MASS WALLS ONLY A I B I C I D I E F I G I H I I I J I K L M Proposed Properties of Masonry and Concrete Added Interior or Exterior Insulation Walls From Reference in Furring Space from Reference Joint Appendix Table 4.3.5, 4.3.6. 4.3.7 Joint Appendix Table 4.3.13 Mass Assembly Name or JA4 Table d o .� . ai E o o OD a °' ^ Final Assembly > �, 5 w �, w U-factor°'' Comment Thickness' T eZ Number' w 3 w a ri n/a n/a 1 _ Indicate the Mass Thickness from Reference Joint 4ppendix JA. 2. Indicate the Assembly Name or type: Roq/Xeiling, Walls, Floors, Slabs, Crawl Space, Doors and etc --- Indicate the Frame type and Size: For Wood, Metal, Metal Buildings, Mass, enter 2x4, 2x6, or etc--- see JA4 for other possible frame type assemblies_ 3. Enter the Table number that closely resembles the proposed assembly- 4- Enter the row and column of the Ufactor value. 5_ Enter the Effective R-value listed in the JA4 Table Number- 6 The Final Assembly is calculated by using Equation 4-1 or Equation 4-4 of the Reference Joint Appendix JA4. Enter the value in Column L. 7. Insert the Final Assembly U-factor value back on to the Opaque Surface Details table in Column J. FENESTRATION PROPOSED AREAS Orientation Fenestration Type and Frame (North, East, ProposedAtea' Maximum Maximum NFRC or (Window, Glass Door or Skyli ) South, West) ftz U-factorz' 3 SHGCZ' 3' ° Default Values' Window North 69 .40 .35 Default Total 69 1 _ Fenestration area is the area of total glazed product (i_e_ glass plus frame)_ Exception: When a door is less than 50•1 glass, the fenestration area may be the glass area plus a "2 inch frame" around the glass_ 2. Enter value from Component Package D Requirements in Table 151-C 3. Actual fenestration products installed and as indicated in CF-6R ENV Form shall be equivalent 10 or have a lower U factor and/or a lower SHGC value than that specked on the Fenestration Proposed Area table above_ 4. Submit a completed WS 3R Form if a reduced SHGC is calculated with exterior shading. 5. ff applicable at this stage enter `1VFRC"for NFRC Certi ed windows or CEC "Default " valuesfound in Table 116 A or B. Registration Number: 2008 Residential Compliance Forms Registration Date/Time: HERS Provider: March 2010 Prescriptive Certificate of Compliance: CF-1R ADD Residential Additions (Page 3 of 5) Site Address: Enforcement Agency: Date: 79-612 E. Mission Dr., La Quinta CA I I October 25, 2011 ADDITION ALLOWED FENESTRATION AREAS A B C D E F nFIA of `W ition Allowed % Allowed Area ReArea AllAn Proposed Areas of CFA (A x B) f1;.2 (C+ D) (Table Above) Total Fenestration Arca3 74 0.20 14.8 69 83.8 > 69 West Fenestration Area .4 74 0OS 8 3.8 > 0 (Required In CZ's 2, 4 & 7 -151 (R . , — 1 _ West Fenestration Area includes west -sloping skylights and any skylights with a pitch less than 1:12. 2. Glass removed to make way for the addition. 3. For additions less than 1,000 fry the xtandardv allows glazing removed during the remodel to be added to the glazing area allowance. The maximum allowed glazing area for the addition is the CFA x 20'9 + glass removed to make way for the addition_ 4_ In climate zones 2, 4, 7-15, no more than 5% of the CFA is allowed jor west facing ghizing plus west facing glass area removed to make way for the addition. The maximum allowed west facing glazing area is the CFA x 5% + west facing glass removed to make way for the addition. 5. To meet compliance, the ProposedArea must be less than or equal to the Total Allowed Area or BOTH the Total and West Fenestration Areas. ROOFING PRODUCTS (COOL ROOFS) §151(1)12 Check applicable box below if the roof addition is exempt from the roofing product "Cool Roof' requirements. Note: If any one of the boxes are checked below, the Aged Solar Reflectance and Thermal Emittance requirements for roofing products in §118(i) are not applicable. Do not fill table below_ Roofing compliance Not Required in Climate Zones 1-12, 14, and 16 with a Low -Sloped- Less or 2:12 pitch_ []Roofing compliance Not Required in Climate Zones 1 through 9 and 16 with a Steep -Sloped. Roofs pitch greater than 2:12 and product weight less than 51b/ff. Roofing area covered by building integrated; photovoltaic panels and solar thermal panels are exempt from the above Cool Roof criteria Roof constructions that have thermal mass over the roof membrane with at least 251bW is exempt from the above Cool Roof criteria. ote:1r no CRRC-1 label is available, this compliance method cannot be used., use the Performance Approach to show comipliame, otherwise, check e applicable box below if Exempt from the Roofing Products "Cool Roof ' Rcquiemcfft: Roof Slope Product Weight Product Aged Solar Thermal CRRC Product ID Number < 2:12 > 2:12 < 52blf'C- > 5Wfi2 Type2 RR4eflectance3'4 Emittance SRIS ❑ El ❑ ❑ LJ NIA (EXISTING ROOF) ❑ ❑ ❑ ❑ ❑`t ❑ ❑ ❑ ❑ 1__I ❑ ❑ ❑ ❑ [344 ❑ ❑ ❑ ❑ IJ ❑ ❑ ❑ ❑ I__I 1. The CRRC Product ID Number can be obtained from the Cool Roof Rating Council 's Rated Product Directory at Hnvw.coab-aofs am iproducIslseareIt. 2_ Indicate the type ofproduct is being used for the roof top, i_e_ single -ply roof, asphalt roof, metal roof, etc. 3. If the Aged Reflectance is not available in the Cool Roof Rating Council's Rated Product Directory then use the Initial Reflectance value from the same directory and use the equation (0.2+0 7(pi i;ar— 0.2) to obtain a calculated aged value_ Where pis the Initial Solar Reflectance_ 4. Check box if the Aged Reflectance is a calculated value using the equation above_ 5_ Calculate the SRI value by using the SRI- Worksheet at httn:Ilunvw_energy.ca_govItille241 and enter the resulting value in the SRI Column above and attach acopy of the SRP Worksheet to the CF-IR. To apply Liquid Field Applied Coatings, the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage recommended by the coatings manufacturer and meet minimum requirements lirements listed in § 118(i)4. Select the applicable coating: ❑ Aluminum -Pigmented Asphalt Roof Coating EJ Cemeut-Based Roof Coating ❑ Other Registration Number: Registration Date/Time: HERS Provider: 2008 Residential Compliance Forms March 2010 Prescriptive Certificate of Compliance: CF-1R ADD Residential Additions (Page 4 of 5 Site Address: 79-612 E. mission Dr., La Quinta CA Enforcement Agency: Date: October 25, 2011 HVAC SYSTEMS - HEATING Duct or Configuration Minimum Distribution Piping (Central, Split, Heating Equipment Efficiency Type and Insulation Thermostat Space, Package or T and ci '° a (AFUE or HSPF) Location° R Value Type Hvdronic) Existing Existing 1. Indicate Heating Type (Central Furnace, Wall Furnace, Heat pump, Boiler, Electric Resistance, etc_) 2. Electric resistance heating is allowed only in Component Package C, or except where electric heating is supplemental (i_e_, if total capacity < 2 KW or 7,000 BWhr electric heating is controlled by a time -limiting device not exceeding 30 minutes)_ See §151(b)3 exception. 3. Refer to the HERS Verification section on Pages 3 and 4 of the CF-IR ADD Form for additional requirements and check applicable boxes. 4. Indicate 7:ype or Location (Ducts, H dronic in Floor, Radiators, etc) HVAC SYSTEMS - COOLING Configuration Cooling, Equipment Type and Capacity],? Minimum Efficiency (SEER/EER or COP) Distribution Type and Location' Duct or Piping Insulation R-Value Thermostat T (Central, Split, Space, Package or Hvdronic) Existing Existing 1. Indicate Cooling Type (A/C, Heatpump, Evap. Cooling, etc)_ 2. Refer to the HERS Verifcation section on Pages 3 and 4 of the CF-lR ADD Form for additional requirements and check applicable boxes. 3. Indicate Tv2e or Location(Ducts, Hydronic in Floor, Radiators, etc_) WATER HEATING List water heaters and boilers for both domestic hot water (DHW) heaters and hydronic space heating_ Individual dwelling DHW heaters must be storage gas or propane fired, non -recirculating, and may not exceed 50 gallons If no natural gas is connected to the building, an electric storage DHW heater less than 50 gallons with an energyfactor greater than 0.90 maybe used. Hot water pipe insulation from the DHW heater to the kitchen(g) and on all undderground hot water pipes is required in 11componentpackages in all climate zones. External Tank Water Heater Type/Fuel Dismnbution Type Number In Tank Energy Factor or Insulation Type' Standard, Recircul stem Capacity (al) Thermal Efficient R-Value3 Existing Existing 1 _ Indicate Type (Storage Gas, Heat Pump, Instantaneous, etc) 2. Recirculating systems serving multiple dwelling units shall meet the recirculation requirements of §150(n)_ The Prescriptive requirements do not allow the installation of a recirculating water heating system for single dwelling units_ 3. The water heating tank and es shall be insulated to meet the requirements of_$150(j). SPECIAL FEATURES The enforcement agency should pay special attention to the Special Features specified in this checklist below. These items may require written justification and documentation and special verification. Applicable special features shall be marked with a YES and be specified within the plans. Radiant Barrier (Roof) YES I x NO I Required in Climate Zones 2, 4, and 8-15 for additions larger than 100 If. Slab Edge (Perimeter) Insulation YES I rxj NO I In Climate Zone 16 under Component Package D, R-7 insulation is required_ Heated Slab Insulation []YES []x NO I Slab edge insulation required for heated slabs in all Climate Zones. See details in Table 118-A of the standards. Raised Slab Insulation []YES Q NO In Climate Zones 1, 2, 11,13,14 & 16 R-8 insulation is required, and in Climate Zones 12 & 15 R4 insulation is required under Component Pac a D. Thermal Mass - To obtain Compliance Credit for the installation of thermal mass, use the Performance Approach_ Registration Number_ Registration Dale/Hme- HERS Provider_ 2008 Residential Compliance Forms March 2010 Prescriptive Certificate of Compliance: CF-1R ADD Residential Additions (Page 5 of 5) Site Address: Enforcement Agency: Date: 79-612 E. Mission Dr., La Quinta CA October 25, 2011 HERS VERIFICATION SUMMARY - The enforcement agency should pay special attention to the HERS Measures specified in this checklist below_ A completed and signed CF-4R Form for all the measures specified shall be submitted to the building inspector before final inspection. Duct Sealing & Testing HERS verification is re uired for this measure. OYES B,i0 In all Climate Zones, if a new space -conditioning system (HVAC equipment and ducting) is installed to serve the addition alone, the ducts are to be sealed and tested per §151(f)10_ DYES In Climate Zones 2 and 9-16, if more than 40 linear feet of new or replacement ducts are installed in unconditioned B iW space to serve the addition, the ducts are to be sealed and tested per § 152(b)1D_ ❑ EXCEPTION: Existing duct systems that are extended, which are constructed, insulated or sealed with asbestos. In Climate Zones 2 and 9-16, if the existing HVAC equipment is replaced (including replacement of the air handler, outdoor condensing unit of a split system, cooling or heating coil, or the furnace heat exchanger) and will serve the addition, the ducts are to be sealed and tested per § I52(b)IE_ ❑YES �� Eko ❑ EXCEPTION: Duct systems that are documented to have been previously sealed confirmed through HERS verification in accordance with procedures in the Reference Residential Appendix RA3. ❑ EXCEPTION: Duct systems with less than 40linear feet in unconditioned space. EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos. Refri erant Ch - Split System HERS verification is requiredfor this measure - OYES ffkO In Climate Zones 2 and 8-15, if a newly ducted split A/C or heat pump is installed to serve the addition alone, a refrigerant charge measurement shall be verified per §151(t)7A. DYES Ei0 In Climate Zones 2 and 8-15, if the existing HVAC equipment is replaced (including replacement of the air handler, outdoor condensing unit of a split system, cooling or heating coil, or the furnace heat exchanger) and will serve the addition, a refrigerant charge measurement shall be verified per § i52(b)1F_ Central Fan Integrated Ventilation System — Airflow and Fan Watt Draw - do not apply for additions 1,000 ftz or less. Ducted Split Systems - Air Conditioners and Heat Pumps: Airflow and Fan Watt Draw HERS verification is required. ❑YES B90 In Climate Zones 10 through 15, if a new space -conditioning system (HVAC equipment and ducting) is installed to serve the addition alone, the airflow and fan watt draw shall be verified per 151(f)7B_ []YES x O In Climate Zones 10 through 15, if the existing space -conditioning system (HVAC equipment and ducting) is replaced and will serve the addition, the airflow and fan watt draw shall be verified per & 152(b)1F. Documentation Author's Declaration Statement • I certify that this Certificate of Compliance documentation is ccurate d cam 1 Name: David Elliottt signatur °may David Elliott Energy Services Date: October 25, 2011 Address: SVL Box fAcablcxEA or E_PE9013 (Certification )_ozt $ City/State/Zip:Victorville CA Phone:760-243-3883 Responsible Building Designer's Declaration Statement • I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on this Certificate of Compliance. • I certify that the energy features and performance specifications for the building design identified on this Certificate of Compliance conform to the requirements of Title 24, Parts 1 and 6 of the California Code of Regulations. • The building design features identified on this Certificate of Compliance are consistent with the information provided to document this building design on the other applicable compliance forms, worksheets, calculations, plans and specus ttesi to the enforcement agency for approval w-ith1 this buildin t application. Name: -FA LA TV E-LSc'a--- Company: � � ` � � � mate: Address: 1 lol �i�l�l Y4U G-'T' License: City/State/Zip: L- VALLF- q2' '77(,0 5t7 - For assistance or questions regarding the Energy Standards, contact the Energy Hotline at. I-800-772-3300. Registration Number: 2008 Residential Compliance Forms Registration DatelTime: HERS Provider: March 2010 Mandatory Measures Summary MF-1R Residential (Pagel of 3 Site Address: Enforcement Agency: Date: NOTE: Low-rise residential buildings subject to the Standards must comply with all applicable mandatory measures listed, regardless of the compliance approach used. More stringent energy measures listed on the Certificate of Compliance (CF-IR, CF-IR ADD, or CF-1R ALTForm) shall supersede the items marked with an asterisk(*) below. This Mandatory Measures Summary shall be incorporated into the permit documents and the applicable features shall be considered by all parties as minimum component performance specifications whether they are shown elsewhere in the documents or in this summary. Submit all applicable sections of the MF-1R Form with plans. DESCRIPTION Building Envelope Measures: § 116(a)l: Doors and windows between conditioned and unconditioned spaces are manufactured to limit air leakage_ § 116(a) 4: Fenestration products (except field -fabricated windows) have a label listing the certified U Factor, certified Solar Heat Gain Coefficient (SHGC), and infiltration that meets the requirements of §10-111(a)_ § 117: Exterior doors and windows are weather stopped; all joints and penetrations are caulked and sealed § 118(a): Insulation specified or installed meets Standards for Insulating Material Indicate type and include on CF-6R Form. § 118(i): The thermal emittance and solar reflectance values of the cool roofing material meets the requirements of § 118(i) when the installation of a Cool Roof is specified on the CF-1R Form_ * § 150(a): Minimum R-19 insulation in wood -frame ceiling or equivalent U-factor_ § 150(b): Loose fill insulation shall conform with manufactu =e s installed design labeled R-Value_ "§ 150(c): Minimum R-13 insulation in wood -frame wall or equivalcnt U-factor_ . § 150(d): Minimum R-13 insulation in raised wood -frame floor or equivalent U-factor. § 150(f): Air retarding wrap is tested, labeled, and installed according to ASTM E1677-95(2000) when specified on the CF-1R Form. § 150(g): Mandatory Vapor barrier installed in Climate Zones 14 or 16. § 150(1): Water absorption rate for slab edge insulation material alone without facings is no greater than 0.3%; water vapor permeance rate is no greater than 2.0 permlinch and shall be protocted from physical damage and UV light deterioration. Fireplaces, Decorative Gas Appliances and Gas Log Measures: § I50(e)1A: Masonry or factory -built fireplaces have a closable metal or glass door covering the entire opening of the firebox § 150(e)1B: Masonry or factory -built fireplaces have a combustion outside air intake, which is at least six square inches in area and is equipped with a with a readily accessible_ operable, and tight -fitting damper and or a combustion -it control device. § 150(e)2: Continuous burning pilot lights and the use of indoor air for cooling a firebox jacket, when that indoor air is vented to the outside of the building, are prohibited. Space Conditioning,Water Heating and Plumbing System Measures: § 1107§113: HVAC equipment, water heaters, showerheads, faucets and all other regulated appliances are certified by the Energy Commission. § 113(c)5: Water heating recirculation loops serving multiple dwelling units and High -Rise residential occupancies meet the air release valve, backflow prevention, pump isolation valve, and recirculation loop connection requirements of § 113(c)5. § 115: Continuously burning pilot lights are prohibited for natural gas: fan -type central furnaces, household cooking appliances (appliances with an electrical supply voltage connection with pilot lights that consume less bran 150 Btu/hr are exempt), and pool and spa heaters_ § 150(h): Heating and/or cooling loads are calculated in accordance with ASHRAE, SMACNA or ACCA_ § 150(i): Heating systems are equipped with thermostats that meet the setback requirements of Section 112(c)_ § 1500)IA: Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are externally wrapped with insulation having an installed thermal resistance of R-12 or greater. § 1500)1B: Unfired storage tanks, such as storage tanks or backup tanks for solar water -heating system, or other indirect hot water tanks have R-12 external insulation or R-16 internal insulation where the internal insulation R-value is indicated on the exterior of the tank § 1500 )2: First 5 feet of hot and cold water pipes closest to water heater tank, nort-recinula i g systems, and entire length of recirculating sections of hot water pipes are insulated per Standards Table 150-13_ § 1500)2: Cooling system piping (suction, chilled water, or brine lines)And piping insulated between heating source and ind-Meet hot water tank shall be insulated to Table 150-B and Equation 150 A_ §1500)2: Pipe insulation for steam hydronic heating systems or hot water systems>15 psi, meets the requirements of Standards Table 123-A. §1500)3A: Insulation is protected from damage, including that due to sunlight, moisture, equipment main(enance, and wind. § 1500)3A: Insulation for chilled water piping and refrigerant suction lines includes a vapor rc larch nt or is c'nciouxi entirely in conditioned space. 2008 Residential Compliance Forms August 2009 Mandatory Measures Summary NLF-1R Residential (Page 2 of 3) Site Address: Enforcement Agency: Date: § 1500)4: Solar water -heating systems and/or collectors are certified by the Solar Rating and Certification Corporation. Ducts and Fans Measures: § I50(m)l: All air-disinbution system ducts and plenums installed, are sealed and insulated to meet the requirements of CMC Sections 601, 602, 603, 604, 605 and Standard 6-5; supply -air and return -air ducts and plenums are insulated to a minimum installed level of R-4.2 or enclosed entirely in conditioned space. Openings shall be sealed with mastic, tape or other duct -closure system that meets the applicable requirements of UL 181, UL 181A, or UL 181B or aerosol sealant that meets the requirements of UL 723. If mastic or tape is used to seal openings greater than 1 /4 inch, the combination of mastic and either mesh orlape shall be used § 150(m)l : Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other than sealed sheet metal, duct board or flexible duct shall not be used for conveying conditioned air_ Building cavities and support platforms may contain ducts. Ducts installed in cavities and support platforms shall not be compressed to cause reductions in the cross-sechunal area of the ducts. § 150(m)21): Joints and seams of duct systems and their components shall not be sealed with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and draw bands. § I50(m)7: Exhaust fan systems have back draft or automatic dampers_ § 150(m)8: Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. § 150(m)9: Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. Cellular foam insulation shall be protected as above or painted with a coating that is water retnrd:rnt and provides shielding from solar radiation that can cause degradation of the material. § 150(m)10: Fkndble ducts cannot have porous inner cores_ § 150(o): All dwelling units shall meet the requirements of ANSI/ASHRAE Standard 62.2-2007 Ventilation and Acceptable Indoor Air Quality in Low -Rise Resident ial Buildings. Window operation is not a permissible method of providing the Whole Building Ventilation required in Section 4 of that Standard_ Pool and Spa Heating Systems and Equipment Measures: § 114(a): Any pool or spa heating system shall be certified to have: a thermal efficiency that complies with the Appliance Efficiency Regulations, an on -off switch mounted outside of the heater, a permanent weatherproof plate or card with operating instructions; and shall not use electric resistance heating or a pilot light. § 114(b)l: Any pool or spa heating equipment shall be installed with at least 36" of pipe between filter and heater, or dedicated suction and return lines, or built-up connections for future solar heating § 114(b)2: Outdoor pools or spas that have a heat pump or gas heater shall have a cover. § 114(b)3: Pools shall have directional inlets that adequately mix the pool water and a time switch that will allow all pumps to be set or programmed to run only during off electric demand periods. § 150(p): Residential pool systems or equipment meet the pump sizing, flow rate, piping, filters, and valve requirements of & 150(p). Residential Li tin Measures: § 150(k)l: High efficacy luminaires or LED Light Engine with Integral Heat Sink has an efficacy that is no lower than the efficacies contained in Table 150-C and is not a low efficacy hirninaire as specified& 150(k)2_ § 150(k)3: The wattage of permanently installed lnmin tres shall be determined as specified by § 130(d)_ § 150(k)4: Ballasts for fluorescent lamps rated 13 Watts or greater shall be electronic and shall have an output frequency no less than 20 kHz. § 150(k)5: Permanently installed night lights and night lights integral to a permanently installed luminaire or exhaust fan shall contain only high efficacy lamps meeting the minimum efficacies contained in Table 150-C and shall not contain a line -voltage socket or line -voltage lamp holder, OR shall be rated to consume no more than five watts of power as determined by § 130(d), and shall not contain a medium screw -base socket. § 150(k)6: Lighting integral to exhaust fans, in rooms other than kitchens, shall meet the applicable requiremerds of § 150(k). § 150(k)7: All switching devices and controls shall meet the requirements of § 150(k)7_ § 150(k)8: A minimum of 50 percent of the total rated wattage of permanently installed lighlmg in kitchens shall be high efficacy. EXCEPTION: Up to 50 watts for dwelling units less than or equal to 2,500 tf or 1 W watts for dwelling units larger than 2,500 W may be exempt from the 50% high efficacy requirmient when: all low efficacy luminaires in the kitchen are controlled by a manual on occupant sensor, dimmer, energy management system (FMCS), or a multi -scene programmable control system; and all permanently installed luminaries in garages, laundry rooms, closets greater than 70 square feed and utility rooms are high efficacy and controlled by a manual -on occupant sensor_ § 150(k)9: Permanently installed lighting that is internal to cabinets shall use no more than 20 watts of power per linear foot ofilluminated cabinet. § 150(k)10: Permanently installed luminaires in bathrooms, attached and detached garages, laundry rooms, closets and utility rooms shall be high efficacy, 2008 Residential Compliance Forms August 2009 Mandatory Measures Summary NIF-1R Residential (Page 3 of 3) Site Address: Enforcement Agency: Bate: EXCEPTION 1: Pennanently installed low efficacy luminaires shall be allowed provided that they are controlled by a manual -on occupant sensor certified to comply with the applicable requimments of § 119. EXCEPTION 2: Permanently installed low efficacy luminaires in closets less than 70 square feet are not required to be controlled by a manual -on occupant sensor. 150(k)l1: Permanently installed luminaires located in rooms or areas other than in latchens. bathrooms, garages, laundry rooms, closets, and utility moms shall be high efficacy luimnaires. EXCEPTION 1: Permanently installed low efficacy luminaires shall be allowed provided they are controlled by either a dimmer switch that complies with the applicable requirements of § 119, or by a manual -on occupant sensor that complies with the applicable requirements of § 119_ EXCEPTION 2: Lighting in detached storage building less than 1000 square feet located on a residential site is not required to comply with § 150(k)l 1. 150(k)12: Luminaires recessed into insulated ceilings shall be listed for zero clearance insulation contact (IC) by Underwriters Laboratories or other nationally recognized testing/rating laboratory, and have a label that certifies the lu irmaire is airtight with air leakage less then 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283; and be sealed with a gasket or caulk between the lumin ai re housing and wdin2. 150(k)13: Luminaires providing outdoor lighting, including lighting for private patios in low-rise wsidential buildings with four or more dwelling units, entrances, balconies, and porches, which are permanently mounted to a residential building or to other buildings on the same lot shall be high efficacy. EXCEPTION 1: Permwicnth• installed outdoor low efficacy luminaires shall be allm,. W provided that they are controlled by a manual onlofi switch, a inrotion sensor not having an override or bypass switch that disables the motion sensor, and one of the following controls: a photocontrol not having an override or bypass switch that disables the photocontrol; OR an astronomical time clock not having an override or bypass switch that disables the astronomical time clock; OR an energy management control system (FMCS) not having an override or bypass switch that allows the lrm maire to be always on EXCEPTION 2: Outdoor luminaires used to comply with Exceptionl to § 150(k)13 may be controlled by a temporary override switch which bypasses the motion sensing function provided that the motion sensor is automatically reactivated within six hours. EXCEPTION 3: Pem)am ntly installed luminaires in or around swimming pool, water features, or other location subject to Article 680 of the California Electric Code need not be high efficacy l rrunaires. § 150(k)14: Internally illuminated address signs shall comply with Section 148; OR not contain a screw-hase socks- and consume no more than five watts of poNwT as determined according to § 130(d). § 150(k)15: Lighting for parking lots and carports with a total of for 8 or more vehicles per site shall comply with the applicable requirements in Sections 130,132, 134, and 147. Lighting for parking garages for 8 or more vehicles shall comply with the applicable requirements of Sections 130. 131. 134, and 146 150(k)l6: Permanently installed lighting in the enclosed, non -dwelling spaces of low-rise residential buildings with four or more dwelling units shall be high efficacy luminaires. EXCEPTION: Permanmtly installed low efficacy lnmmaires shall be allowed provided that they are controlled by an occupant sensor(s) certified to comply with the applicable ro uircmcuts of § 119_ 2008 Residential Compliance Forms August 2009 P.O. BOX t504 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-Bul1ders Applying for Construction Permits IMPORTAM'! NOT-CE TO ERQPER1Y Q3Y R Dear Property Owner: An I application for a building pmnit has been submitted - your name listing yourself as the builder of the property improvements specified at We are prWiding you with an Owner -Builder Acknowledgment and lnfot7natiOn Verification Form to make you awam of year reSPOttsibilities and possible risk you may incur by having this permit issued in your name as the Owe -Builder. We will not issue a building Wudt until you have read, initialed your understanding of eack provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute tbis notice unless you, the property owner, obtain the prior approval of the permitting authority. OAR'S AQQnW_ ,EDG�T ANa VERWLCATI0N 4F INFIOBMAMN MEC-T ONS., React and initial ,,=1f staterrreW-beiow tw signify you understand or very deis information. 1. I understand a frequent practice Of unlicensed persons is to have the property owner obtain an "Owner -Builder" building permit that errancously implies that the property owner' 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 woriong on my property. My homeowner's insurance may not provide coverage for those injunes- 1 am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers an qiy property. J2. 1 understand building permits are not required to be signed by property owners unierss they are responsible for the co traction and are nut hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an "owner -Builder" I am die 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. J"4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on pe is and contracts. 75. 1 unde rstand if 1 employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five Hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law_ _�16. I understand if I am considered an "employer" under state and federal law, I must register with the state and federa govenunent, withhold payroll taxes, provide woiicers' compensation disability insurance, and contribute to unemploymen cisko asubon for each "employee." I also understand my failure to abide by these laws may subject rife to serious frnancia r T 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residenti: structures cannot legally build there with the intent to offer them for sale, unless all work is performed by license subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performs under contract with a licensed general building Contractor. �8. Lun - t is issued, be held liable for any derstand as an Owner -Budder if I sell the property for which this permit �, I may financial or personal 'injuries sustained by any subsequent owners) that result from any latent construction defects in the workniansliip or materials. . 1Q 9. 1 understand I may obtain more information regarding my obligations as an "employee' from the bateml 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 I - 800-32 1 -CSLB (2752) or www.csib.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 Lam the p legally and financially responsible for . proposed construction activity at the following address, y I I. I agree that, as the party legally and ftnamcially responsible for tbis proposed construction activity. I will abide by all applicable laws and. requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the infomtation 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, dw 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 &m is injured whale 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 respowke for vcrdy* wb dxw or not those Contractors are properly licensed and the status of thm workers' Compensation insurance eovertrge. 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 inv ttg.&e permit. Nora: A copy of dw property awner's di*er N1kMse, fnrttc nrrtarx0mt'vn; or other verification acceptable too dte agency is required to be presented when A* pemat is issued to •DIY Ike property owner's signature. Signature of property owner , J C� Date--1, r3 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 A. ENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I underrstimd. is my personal responsibility, I hereby authorize the following person(s) to act as my qgent(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 persoa$lIy filled out the abo information and certify its accuracy. Note: A copy of the owner's driver's license, form notariration, 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: