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BRER2019-009278-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Permit Type/Subtype: Application Number: Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: MEIR BEN SHOSHAN 53665 AVENIDA CORTEZ LA QUINTA, CA 92253 TivI ^F lP Qu&M DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT RE -ROOF/ BRER2019-0092 53665 AVENIDA CORTEZ 774101013 SHOSHAN / REROOF ENTIRE DWELLING WITH ASPHALT SHINGLES $10,000.00 VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 5/20/2019 Owner: MEIR BEN SHOSHAN 53665 AVENIDA CORTEZ LA QUINTA, CA 92253 iz D Contractor: (J *--' OWNER BUILDER - MEIR BEN SHOSHAN 53665 AVENIDA CORTEZ MX( 2 1 2019 LA QUINTA, CA 92253 P D (760)994-7292 D qq IryCIT,y OF I-AQyU{(Y��TA [TNIGNLlc. No.::CONV:140528101254126527 KIIGN 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.::CONV:1405287.01254126527_ 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 he applicant to a civil penalty of not more than five hundred dollars ($500).: VI ownerofthe property, or my employees with wages as their sole tion, w I I I do the work, and the structure is not intended or offered for sale. (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he A"or not build or improve for the purpose of sale.). asowner of the property, am exclusively contracting with licensed contractors to ruct the project. (Sec.7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). (_) I am exempt under Sec. B.&P.C. for this res n zn f Dater Owner: ✓ CONSTRUCTION LENDING A(j I hereby affirm under penalty of perjury that there is a ` nst 'fendirl geney for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.), Lender's Name: Lender's Address: 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 orkers' compensation insurance carrier and policy number are: Carrier ollcy Number: I ertify that in the performance of the work for which this permit is issued, I sh mpIoy any person in any manner so as to become subject to the workers' c mpensation laws of CaIifarnia, and agree that, if i should become su ject to the workers' compensation provisions of Section 3700 of the ab Co . i all forthwith comply with ose provisions. Date: Applicant: % WARNING: FAILURE TO SECURE WORKERS' COMPENSAT<N COVUXGE 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 bulldin construction, and h eby authorize representatives of this city to enter up the a e- mentioned proper four inspection purposes. Date:/ Signature (Applicant or Agent): vr� y �+ 5/20/2019 Application Number: Property Address: APN: Application Description Property Zoning: Application Valuation: Applicant: MEIR BEN SHOSHAN 53665 AVENIDA CORTEZ LA QUINTA, CA 92253 BRER2019-0092 53665 AVENIDA CORTEZ 774101013 SHOSHAN / REROOF ENTIRE'DWELLING WITH ASPHALT SHINGLES $10,000.00 Owner: MEIR BEN SHOSHAN 53665 AVENIDA CORTEZ LA QUINTA, CA 92253 Contractor: OWNER BUILDER - MEIR BEN SHOSHAN 53665 AVENIDA CORTEZ LA QUINTA, CA 92253 (760)994-7292 Llc. No.::CONV:140528101254126527 Detail: REROOF WITH OWENS CORNING ASPHALT SHINGLES (SHASTA WHITE) AT SLOPED AREAS [CRRC; 0890-0008] PER 2016 CALIFORNIA ENERGY CODE. Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT QTY AMOUNT RE -ROOF - EA ADDITIONAL 1,000 SF 101-0000-42404 0 $12.81 DESCRIPTION ACCOUNT QTY AMOUNT RE -ROOF - FIRST 2,000 SF 101-0000-42404 0 $54.43 DESCRIPTION ACCOUNT CITY AMOUNT RE -ROOF - FIRST 2,000 SF PC 101-0000-42600 0 $108.87 Total Paid for RE -ROOF: $176.11 DESCRIPTION ACCOUNT CITY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 TOTALS: $182.11 0890-0008 Clear Filters x 5_HQW FILTERS 1 SEARCH RESULTS A CRRC product rating describes the radiative performance of a roofing material; it does not indicate a ranking or approval. A product's placement on the Rated Products Directory (Directory) does not mean that the product is "cool" as defined by any particular code or program. Only products with active ratings can be found on the Directory. Read More CRRC PROD. ID MANUFACTURER BRANDANDMODEL PRODUCTTYPE COLOR o89o-0008 Owens Corning TruDefinition® Duration® Cool Asphalt Shin Bright Roofing and Shasta White I RapidEdgel Pre -Cut gle White Asphalt, LLC Rake Starter Shingles Shasta White TruDefinition® Duration® Shasta White SOLAR REFLECTANCE THERMAL EMITTANCE SRI INITIAL 3YEAR INITIAL 3YEAR INITIAL 3YEAR 0.25 0.29 0.94 0.87 27 29 COOL ROOF RATING COUNCIL 2435 N. Lombard St. TEL (866) 465-2523 EMAIL: info@coos oofs.org Portland, OR 97217 PRINT EXPORT ALL PRODUCTS Showing i-t of t result MORE INFO Showing 1-1 of t result Certificate 3146.oi STATE OF CALIFORNIA Prescriptive Residential Alterations That Do Not Require HERS Field Verification CEC-CFi R-ALT-05-E (Revised 04i16) CERTIFICATE OF COMPLIANCE Prescriptive Residential Alterations That Do Not Require HERS Field Verification I nls compliance document is only applicable to with a HERS Provider Data Registry. not require HERS ERGY COMMISSION® CF1R-ALT-05-E Pagel of 3 compliance. When HERS verificotion is required, a CF1R-ALT- 01 shall first be registered Alterations to Space Conditioning Systems that ore exempt from HERS verification requirements may use the CF1R-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 not exempt from HERS verification, then a CF1R-ALT-02 must be completed and registered with a 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 on 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 CF1R-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 Information 01 Project Name: 02 04 Date Prepared: 03 Project Location: �n, Building Front Orientation (deg or cardinal): f I b' 05 CA City: 06 Number of Altered Dwelling Units: 07 Zip Code: e) e-i [� 08 Fuel Type: 09 Climate Zone: �r'"' 10 Total Conditioned Floor Area (ft): "7 f - 11 Building Type: , / �� / 12 Slab Area (ft) 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. & F. Fenestration/Glazing - REPLACE ❑ H. Water Heating System ❑ Include Mandatory Measures? CA Building Energy Efficiency Standards - 2016 Residential Compliance April 2016 a STATE OF CALIFORNIA Prescriptive Residential Alterations That Do Not Require HERS Field Verification CEC-CFIR-ALT-05-E (Revised 04116) CALIFORNIA ENERGY COMMISSION IM CERTIFICATE OF COMPLIANCE CF1R-ALT-05-E rPrescriptive Residential Alterations That Do Not Require HERS Field Verification Page 2 of 3 C. Roof Replacement (Prescriptive Alteration, Section 150.2(b)1H) 01 02 03 04 05 Method of Compliance Roof Pitch Exception CRRC Product I ID Number Product Type Sic 08 go -ows I�UIL�iT l b wl 06 07 08 1 09 10 11 1 12 1 13 Proposed Minimum Required R-value Deck Insulation Initial Solar Aged Solar Reflectance Reflectance Thermal Emittance SRI (Optional) Aged Solar Reflectance Thermal Emittance SRI (Optional) 0 .2-5' 1 0.29 o'. 9y Z- 7 1 0. 20 0.75" l (o Add Row Defete Row 4SPItNur 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 ^.�^RNIA Prescriptive Residential Alterations CEC-CFIR-ALT-05-E (Revmed 04/16) CERTIFICATE OF COMPLIANCE That Do Not Require HERS Field Verification Prescriptive Residential Alterations That Do Not Require HERS Field Date MMISSION® CF 1R-ALT-05-E Page 3 of 3 DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Compliance documentation Is accurate and complete. Documentation Author Name: Documentation Autho Si a urea Signature Date: 57 1 `10fq Company: Address: CEA/ HERS Certification Identif ation Jif applicable): City/St a /lip: 9 �2 Phone: s'-3 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: i � P—i r,i7�J� oil C Company : Date Signed: Address: ��/ ✓Y ✓J�Wc/ ✓ `- 1V`v` 7 License: CityJStatel2ip: 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 Qaigra (A[ IFORNIA _ PERMIT # P N ATION: Project Address:J-36,�,JAz, Project Description: APN #: 2-rL-n _ 00 Applicant Name:� ,n _ Address:170 r , City, ST, Zip h,. (� Telephone: qJ -- 2-,2 J Email:���ss�� Valuation of Project Contractor Name: New SFD Construction: Address: Conditioned Space SF City, St, Zip Garage SF Telephone: Patio/Porch SF Email: Fire Sprinklers SF State Lic: City Bus Lic: Architect/Engineer Name: Construction Occupancy: Address: Grading: City, St, Zip Telephone: Bedrooms: Stories: # Units: Email: State Lic: City Bus Lic: Property Owner's Name: New Commercial / Tenant Improvements: Address: y- ' �� Total Building SF City, ST, Zip t c. 92M Construction Type: Occupancy: Telephone: 9_ - Email: 78495 CALLE TAMPICO LA QUINTA, CA 92253 760-777-7000 OFFICE USE ONLY # Submittal Required Received 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 T4hf °F 4a" 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? S4ANWUP 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: IIii hest Benerits 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 Sienificant financial Risk: Owner -as -Employer is a type of Owner -Builder where you pay any unlicensed individual to perform any construction work valued at more than $500.00, the permit is taken out in your name and you are personally responsible for their employment requirements, supervision, performance, safety and welfare while on your property. WARNING: Cost savings benefit can turn to serious financial risk if you fail to deduct payroll taxes or provide workers compensation insurance for each worker. Benefit/Risk: Possille 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 inrli 1rlo %At A mmnehin onrl urrare' nmm�onco4inn ices ine W^morvwnere ci iffor financial harm rh io 4n yllV hicl a vwoikIIIanship and wwo,ke- VV II.rJV1wtion VVVVV . VVV.V.V VVVwVM...VVV •V defective workmanship and injured employees. Following are alarming examples of what has occurred with Owner -Builder permits: Example 1: Homeowner received insurance money to rebuild burned -down home. • Owner/Builder permit pulled to rebuild structure. • Unlicensed contractor built substandard structure — must be torn down and replaced. • Estimated financial injury is $225,000. • Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of the year. Example 2: Brother-in-law had active license but filed an exemption from Workers Comp. • Owner -Builder hires brother-in-law to install a new roof. • Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and remains in a coma to this day. • The Owner -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic system and suffers injury that results in permanent disability. • The Owner -Builder did not have a homeowner's insurance policy on the house against which to submit a claim. • The Owner -Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Did you know — unlicensed persons frequently have the property owner obtain an "Owner -Builder" building permit which erroneously implies that the property owner is providing his or her own labor and material personally? Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your property by an unlicensed contractor and his/her employees? Did you know — if you are considered an "employer" under state and federal law, you must register with the state and federal government, withhold payroll taxes, provide workers compensation and disability insurance and contribute to unemployment compensation for each "employee"? Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk? OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR YOUR CONSTRUCTION PERMIT T-111ur 4 4 a" 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 4 % e i i (IQ . q1l We are providing you with an Owner -Builder Acknowledgment and InfoirnationTerification 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 signify you understand or verify this information. L I understand a Frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder„ riding 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. JEW2. I understand building permits are not required to be signed by property owners unless they are responsible for the 'It and are not hiring a licensed Contractor to assume this responsibility. !It3 I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect yself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my 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 licensed Contractors, and the total value ❑ my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. ( go 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 ris 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential s ctures 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. P;�8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any nancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. kervi 9. 1 understand I may obtain more information regarding my obligations as an "employer' from the Internal Revenue ce, 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- 804-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. IQ. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the pa legally and fviancially r ponsib a for propo ed cons ction activity at the following address: L3 I 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. i`d 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I ve provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to t gei y is required o be resented when the permit is issued to verify the property owner's signature. 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 perrnit 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: S266 -' AIM43el C0 _ Lit lfi2U -1* q Name of Authorized Agent: O _y 2)7 Tel No ] r (2 y 2— Address of Authorized Agent: Cnt - eLj� j V,4 26L e��2.65-q 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 requi to presented When the permit is issued to verify theproperty owner's signature. Property Owner's Signature: ` Date: 0Z