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BPLB2019-009178-495 CALLE TAMPICO C� 0 D 4v LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT Permit Type/Subtype: PLUMBING/ Application Number: BPLB2019-0091 Property Address: 49786 COACHELLA DR APN: 646240004 Application Description: MECHELKE / WATER HEATER FINAL Property Zoning: a Application Valuation: Applicant: MARIAANE NOUSKAJIAN JUN 12 2019 49715 ANACAPA CIR LA QU I NTA, CA 92253 CITY OF LA 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.: 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 ub- cts the applicant to a civil penalty of not more than five hundred dollars 10110, I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale. (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he r she did not build or improve for the purpose of sale-). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project. (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the ntractors' State License Law.). I am exempt under Sec. B.&P.C. for this reason Date: CONSTRUCTION LENDING AGENCY 1 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: 6/12/2019 Owner: Mechelke Family Trust 49786 COACHELLA DR LA QUINTA, CA 92253 Contractor: N/A ASBUILT CONDITION Llc. No.: WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Car ier: Policy Number:_ I certify that In the performance of the work for which this permit is issued, I shall not employ a ny 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. I Date: 6— 12 ` Applican �- WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 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 to enter upon the above - mentioned property for inspection purposes. Date/�—/ Signature (Applicant orAgent: Date: 6/12/2019 Application Number: Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: MARIAANE NOUSKAJIAN 49715 ANACAPA CIR LA QUINTA, CA 92253 BPLB2019-0091 49786 COACHELLA DR 646240004 MECHELKE / WATER HEATER FINAL Owner: Mechelke Family Trust 49786 COACHELLA DR LA QUINTA, CA 92253 Contractor: N/A ASBUILT CONDITION Llc. No.: ----------------------------------- - ---t - i --------------------------------------- Detail: HOT WATER HEATER INSTALLED IN 2004 PERMIT FOR FINALTO CLOSE OUT PREVIOUS PERMIT PLBG-04-3898.CARBON MONOXIDE ALARM(S) TO BE INSTALLED PRIOR TO FINAL INSPECTION. 2016 CALIFORNIA BUILDING_ CODES. ._ FINANCIAL INFORMATION DESCRIPTION ACCOUNT CITY AMOUNT PERMIT ISSUANCE 101-0000-42404 0 $101.40 Total Paid for PERMIT ISSUANCE: $101.40 DESCRIPTION ACCOUNT CITY AMOUNT WATER HEATER/VENT 101-0000-42401 0 $13.34 DESCRIPTION ACCOUNT CITY AMOUNT WATER HEATER/VENT PC 101-0000-42600 0 $8.00 Total Paid for PLUMBING FEES: $21.34 DESCRIPTION ACCOUNT CITY AMOUNT RECORDS MANAGEMENT FEE 101-0000-42416 0 $10.00 Total Paid for RECORDS MANAGEMENT FEE: $10.00 DESCRIPTION ACCOUNT CITY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 ta Qal�tra ...,:01RNI t -- Project Address: APN #: Applicant Name:/4L4,0L1,fUX- Aft,0 Address:q'(715 4`tci� City, ST, Zip: , ��!/r- '7:;� 3 Telephone: ?/a 3 Email -- Contractor Name: Address: 4S boyt City, St, Zip Telephone: Email: State Lic: City Bus Lic: Architect/Engineer Name: Address: City, St, Zip Telephone: Email: State Lic: City Bus Lic: Property Owner's Name Addr!Mj City, TelepEmailrN • e PERMIT # ?pZ,A201 q- Project Description: C3� � �J►�.r'i C � NC Valuation of Project $ New SFD Construction: Conditioned Space SF Garage SF Patio/Porch SF Fire Sprinklers SF Construction Occupancy: Grading: Bedrooms: I Stories: I # Units: New Commercial / Tenant Improvements: Total Building SF Construction Type: Occupancy: 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 City Business License r STATE OF CALIFORNIA Prescriptive Residential Alterations That Do Not Require HERS Field Verification CEC-CF1 R-ALT-05-E (Revised 04/10) CERTIFICATE OF COMPLIANCE - Prescriptive Residential Alterations That Do Not Require HERS Field Verification Project Name: 4f 'F7 Ir ` I a ENERGY COMMISSION CF113-ALT-05-E Pagel of 3 a -his compliance document is only applicable to simple alterations that do not require HERS verificatron for compliance. When HERS verification is required, a CF1R-ALT- 01 shall first be registered with a HERS Provider Data Registry. Alterations to Space Conditianing Systems that are exempt from HERS verification requirements may use the CF1R-ALT--05 and CF7R-ALT-05 Compliance Documents. Possible exemptions from duct leakage testing include: less than 40 ft of ducts were added or rep loced; 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-AtT-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 Tess than 2.5 pounds per cubic foot having an R-valve 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. I Temporary labels shall not be removed before verification by the building inspector. A. General Information 01 Project Name: 0 7 (� � ���I 0 /t� 02 Date Prepared: (, (� I 03 Project Location: CA City: G 04 06 Building Front Orientation (deg or cardinal): Number of Altered Dwelling Units: G 05 Zip Code: 08 Fuel Type: ~� 411Building Climate Zone! 10 ' Total Conditioned Floor Area (ftZ):• 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 STATE OF CALIFORNIA Prescriptive Residential Alterations That Do Not Require HERS Field Verification CEC-CF1 R-ALT Or-E (Revised 04116) _ CERTIFICATE OF COMPLIANCE Prescriptive Residential Alterations That Do Not Require HERS Field Verification Project Name: Water Heating Systems (Section 150.2(b)1G) 01 02 03 04 05 Water Watex Heating Heating System Dwelling System Location or Water Heating Water Unit Name ID or Name Area Served System Type Heater Ty Add Row I Delete COMMISSION11111111111iiiiiiiiiiiiiiii CF1R-ALT-05-E Page 2 of 3 Date 06 07 08 09 10 11 12 13 14 15 # of Water Water Back -Up Heaters Heater Rated Heating Heating Exterior Solar in Storage Fuel Rated Input Efficiency Efficiency Standby Insulation Savings System Volume (gal) Type Input Type Value Type Value Loss (%) R-Value Fraction �S�' . C�� K� .LFu.� y21 CA Bullring Energy Efficiency Standards - 2016 Residential Compliance April 2016 STATE OF CALIFORNIA Prescriptive Residential Alterations That Do Not Require HERS Field Verification CEC-CF1 R-ALT-05-E {Revised 04/1fi CERTIFICATE OF COMPLIANCE CALIFORNIA ENERGY COMMISSION Prescriptive Residential Alterations That Do Not Require HERS Field Verification CF1R-ALT-05-E r'rv}esr Name: 79 �/+} �,y �j /j /'� Page 3 of 3 VV��11 ' ` . f �-L�L [ 91 ✓1 i - C'f`� Y '7 1 C� Hate Prepal7�d ■ ^ ■ DOCUMENTATION AUTHOR'S DECLARATION STATEMENT I. I certify that this Certificate of Compliance documentation is accurate and complete. Documentation Author Name: a� G. �� n r 6 [ion AuthwSignature: Company: 1 `e / V �'i li S k ({ l� J Signature Date: �r�rk�� Sn�r�l�,r-s g�-r�-�� Address: ( C/o1 S 1i CEA/ iiERS CertifEcavon IdenMation (if applicabEe) -/ "I /�f-YL /Z � J Citylst telzip: Pliane: 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. I 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 bui Ider provides to the building owner at occupancy. Responsible Designer Name: Responsible Desigrrer Signature: Co�ny1L.-rCgi/�91� �GU S�� 1l Pate Signed' Address: ( -7 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 T-111af 4 4Q" P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 79-495 CALLS TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT - PROPERTY OWNER'S PACKAGE (760)777-7012 FAX (760) 777-701 l Disclosures & Forms for Owner -Builders Applying for Construction Permits IMRORTANTI NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a buMlin errruit has su mi d in your name listing yourself as the builder. of the properly improvernents specified at - 7 e * 4 117k Dr. We are providing you with an Owner Builder Acknowledgment and information Verification Form to make you aware of your respausbilities and possible risk you may in=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 ofthe permitting authority. OWNER'S ACKNOWLEDGMENT AND V•ERMCATION OF INFORMATION DIREC770 B: Read and initial each statement below to signify you understand or verify this information. G1. 1 understand. a frequent practice of unlicensed persons is to have the property owner obtain an "Owmmr-Builders' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her ernployees 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. 2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. C).,?- 3. I understand as an "Owner -Builder" I am the 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. _A. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. Q,P—, rs5. I understand if l employ or otherwise engage any peons, other than Californialicensed Contractors, and the total value omy construction is at least five hundred dollars ($500), including labor and materials, I may be consid=d an "employer" under state and federal law. C)--P--., 6. I 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 sure to serious financial rjsk. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build therm with she intent to offer them for sale, }unless all work is perfor=d by licensed subcontractors and the number of structures does not exceed four within, any calendar year, or all of the work is pctfonmted under contract with a licensed general building Contractor. S. I understand as an Owner -Builder if I sell the property for which th s Permit is ' p issued, I may be held i:abA for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction dcfms in the workmanship or materials_ 9. 1 understand I may obtain more information regarding my' obligations as an "employer" from the Internal Revenue Service, the Unitcd States Small Business Administration, the California Depgrrrncnt of Benefit Payments, and the California of Industrial Accidents. 1 also understand I shay contact the California Contractors' State License Board (CSL13) at 1- 800-321-CSLB (2752) or www.cs[b.ca.gov for more information about licensed contractors. 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally, and financially reVonsible for purposed cnristruction activity at the 'following address: C�__�I 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide b all ' aTpplrcable laws and requirement$ that govern Owner -Builders as well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form Licensed contractors In regulated by laws designed to protect the public. Lf 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 conxplaint Your only remedy against unlicensed Contractors may be in civil court It is also irupottant for you to understand that if are unlicensed Contractor or employee of that individual or fern 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 t5cir 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. Notes A copy of the property owner's driver's license, fors: notorirdtin, o or other verification acceptable to the agency Is required to be presented when the permit is issued to verify the property owner's signature. Signature of property owner Date: . -Lai 4� Note: The fol/owing Authorization Form is required to be completed by the property owner only when designating an agent of theproperty owner to apply for a construction permit for the Owner -Bull der. AUTHOR%ZATiON OF.GENT TO ACT ON PROPERTY OWNERS n Excluding the Notices to Properly Owner, the execution of which I uadctstgnd is my Personal responsibility, I hereby authorize Permit for my project the following Person(s) to act as my agent(s) to apply for. sign, and file the documents necessary to obtain an Owner -Builder .� Scope of Construction Project (or Description of Work): 15 e Jiro Project Location orAddress:��7q-��b COUIUl/Q. Dr. /I w)i a err 92253 - Name of Authorized Agent 417t rl -40 Me. k2 r I a yI Tel No (� _ �� 5) g -]/ z 3 ,1 Address ofAuthorizedAgent: '7?7/J' 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 ccm#y its accuracy. !Vote: ,q copy of the ❑wner's driver's Ifcense, farm notarization, or other verification acceptable to the r�gertcy i s required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature. Date: 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 t has cen suDmid in your name listing yourself as the builder of the property improvements specified at - -7 Q e 0 A- D r. We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the pernutting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DI IONS: ,Read and initial each statement below to sign you understand or verify this information. 1_ I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" building 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 wiIifiiIly acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers nn nsy roPertY 2. I understand building permits are not required to be signed by property owners unless they are responsible for the constru tion and are not hiring a licensed Contractor to assume this responsibility. 3. II understand as an "Owner -Builder" I am the responsible a spo e 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 ❑wn. V.4_ I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on perim and contracts. 5. I understand if I 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. *—*I 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 r= to serious financial risk, understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the wor anship or materials. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue ervice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1- 800 (2752) or www.cslb.ca.gov for more information about licensed contractors. ATIO. I am aware of and consent to an Owner -Builder building permit applied form my name, and understand that I am the party legally, and financially responsible for proposed construction activity at the following address: �11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applic le laws and requirements that govern Owner -Builders asmell as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. $t is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. �' Signature of property owner r�'�. Date: �� l 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. AUTHORTTATION 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): F P• .�' lr 71 1 Pj 'r%4j 1� �� l � h�i-7 Uj!%e�S Project Location or Address: 0 - 7 06 Coaeht://a Dr. l9 a►�l ' , OW 99 z 5.3 - Name of Authorized Agent: f'1 %� rl W1 r7P. lV Dyi�j'W1 � y1 _Tel No Z� � a1 �1 . 712 3 Address of Authorized Agent: 07111)� 11h a e p it (fill',' �, a 6 y/ rj �qL 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 re t to be resented when the permit is issued. to verb the property owners signature. Property Owner's Signature-'- - vv" �yl�.'� ��"`- Date: