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BMCH2019-022978-495 CALLE TAMPICO C& U D LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT Permit Type/Subtype: MECHANICAL/ Application Number: BMCH2O19-0229 Property Address: 49786 COACHELLA DR APN: 646240004 Application Description: MECHELKE / HVAC CHANGEOUT FINAL Property Zoning: Application Valuation: Applicant: MARIANNE NOUSKAJIAN FJUN 12 2019 49715 ANACAPA CIR ]D LA QUINTA, C 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.: Date: Contractor: OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: _XPII, as owner of the property, or my employees with wages as their sole compensation, will do the work, and She 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 sh!e� did not build or improve for the purpose of sa.le.). �]U,_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 C ntractors' State License Law.). am exempt under Sec. B.&P.C. for this reason Date: Owner: 7V' tal CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction len ' g agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Na 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 AS BUILT 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 far which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, forthe performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carr'q Policy Number: L '0 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provissiions. , Date-—�� I Applicant: i 4 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 ofthis 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 or Agen� L�sc� { Date 6/12%2019 Application Number: Property Address: APN: Application Description Property Zoning: Application Valuation: Applicant: MARIANNE NOUSKAJIAN 49715 ANACAPA CIR LA QUINTA, C 92253 BMCH2O19-0229 49786 COACHELLA DR 646240004 MECHELKE / HVAC CHANGEOUT FINAL Owner: Mechelke Family Trust 49786 COACHELLA DR LA QUINTA, CA 92253 Contractor: N/A AS BUILT - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Detail: HVAC CHANGE OUT - 80 AFUE FURNACE AND INDOOR COIL.TO FINAL AND CLOSEOUT MECH-10-233. CARBON MONOXIDE ALARM(S) TO BE INSTALLED PRIOR TO FINAL INSPECTION. PER 2016 CALIFORNIA BUILDING CODES. FINANCIAL • • DESCRIPTION ACCOUNT CITY AMOUNT HVAC CHANGEOUT - FURNACE ONLY 101-0000-42402 0 $40.02 DESCRIPTION ACCOUNT CITY AMOUNT HVAC CHANGEOUT - FURNACE ONLY PC 101-0000-42600 0 $26.68 DESCRIPTION ACCOUNT CITY AMOUNT HVAC CHANGEOUT - REPAIR/ALTERATION 101-0000-42402 0 $13.34 DESCRIPTION ACCOUNT CITY AMOUNT HVAC CHANGEOUT - REPAIR/ALTERATION PC 101-0000-42600 0 $5.34 Total Paid for CHANGEOUT: $85.38 DESCRIPTION ACCOUNT CITY AMOUNT PERMIT ISSUANCE 101-0000-42404 0 $101.40 Total Paid for PERMIT ISSUANCE: $101.40 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 • Project Address: V2 ��,� }r]/ APN #: !� �V/,IIA Applicant Name:A4,<6e/,q,—,1�x� oU Address_'/g71,5 �h4C a Ctv� City, ST, Zip:' � QL4A '7:; 3 Telephone: -7/a 3 Email: Contractor Name: Address: 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: Address: City, ST, Zip r Telephone: r 4; Email: ie✓i� , eta! 7 &,e Our VU =PERMITJ/VC2C1 P LA fV_ LOCATIO N : 4Project Description: Valuation of Project $ New SFD Construction: Conditioned Space SF Garage SF Patio/Porch SF Fire Sprinklers SF Construction Occupancy: Grading: Bedrooms: Stories: i # Units: New Commercial / Tenant Improvements: Total Building SF Construction Type: Occupancy: ` [(. cam 78495 CALLE TAM PICO LA QUINTA, CA 92253 760-777-7000 r STATE OF CALIFORNIA ALTERATIONS - HVAC CEC-CFIR-ALT=Q4-E (f evrsed 01/15) CERTIFICATE OF COMPLIANCE Alterations - HVAC CZ 2, and 8-15 ENERGY COMMISSiON CF1R-ALT-04-E (Page 1 of 1) 31MMUlorr. Enforcement Agency: Date re ared: Permit#: l Equipment T e New Ducting or Lineset: Conditioned Type Equipment Efficiency Required R-value Floor Area (ftZ) Thermostat ❑ Packaged Evaporator Coil COP ❑ R-6 (CZ 1-10, 12&13) Ducts Served by system ❑ Setback Sys m ❑Condensing Unit ❑ R-8' (CZ11, 14-16) Ducts I,ZQ�-{t' (If not alreody Split System ❑ Compressor SEER HSPF ❑ > R-2.8 Lineset' present, must d❑Mini Split El Lineset be installed) Furnace ❑ TXV EER HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this form Is allowed to be filled out by hand. For final inspection all forms are to be registered (no hand filled forms allowed) and a copy left on site. 1. HVAC Changeout/Repair Required Compliance Documents to be left on site for Final: All Equipment, CF1R-ALT-02-E Condenser Unit, Evaporator Coil, CF2R-MCH-01-E, MCH-20-H, MCH-(23 or 24)2-H, MCH-25-Hz Compressor, TXV,,Lineset, CF3R-MCH-20-H, MCH-(23 or 24)-H2, MCH-25-H2 Air Handler/Furnace' (Can include new ducting) Installer Requirement: Duct leakage (< 15%, or _<10% to outside, or seal all accessible leaks), Air Flow >_ 300 CFM/ton, Refrigerant Charge. Exempted from duct leakage testing if: ❑ 1. Duct system registered with HERS provider as previously sealed, or ❑ 2. There Is less than 40 linear feet of duct In unconditioned space, or ❑ 3. Existing duct systems are constructed, insulated or sealed with asbestos (list manufacture date of building- 0 2. New HVAC System Required Compliance Documents to be left on site for Final: All new equipment and All New Ducts' CF1R-ALT-02-E including Mini Split CF2R-MCH-01-E, MCH-20-H, MCH-22-H, MCH-(23 or 24)-H', MCH-25-H2 CF3R-MCH-20-H, MCH-22-H, MCH-(23 or 24)-H', MCH-25-H2 Mini Splits require -- --ALT-02-E, CF2R-MCH-01-E, and (CF2R-CF3R) MCH-25-H Installer Requirement: Duct leakage < 5%, Fan Efficacy (0.58W/CFM), Air Flow >_ 350 CFM/ton (or alternative), Refrigerant Charge ❑ 3. All New Ducts with Replacement Required Compliance Documents to be left on site for Final: All New Ducts' and one or more of the following CFN-ALT-02-E replaced: Condenser Unit, Evaporator Coil, CF2R-MCH-01-E, MCH-20-H, MCH-(23 or 24)-H, MCH-25-H Compressor, TXV, Lineset, Furnace CF3R-MCH-20-H, MCH-(23 or 24)-H, MCH-25-H Installer Requirement: Duct leakage < 5%, Air Flow> 350 CFM/ton (or alternative), Refrigerant Charge Exempted from duct leakage testing if: ❑ 1. Existing duct systems are constructed, insulated or sealed with asbestos ❑ 4. New Ducting over 40 feet Required Compliance Documents to be left on site for Final: New ducting but less than All New Ducts' CF1R-ALT-02-F, CF2R-MCH-20-H, CF3R-MCH-20-H Installer Required to: Duct leakage (< 15% or, <_10% to outside or, or seal all accessible leaks) ❑ EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos. All new ducting requires R-8 insulation when more than 40 ft installed in CZs 11 & 14-16 and R-6 in CZs 1-10, 12 &13, and R-6 insulation when less than 40 ft installed. This includes in walls, between floors etc. Z Heating only systems and Air Handler/Furnace changes do not require Air Flow MCH-(23 or 24), or Refrigerant Charge verification MCH-25 ' All New Ducts is when at least 75%of the duct system is new duct material, and up to 25%may consist of reused parts from the dwelling unit's existing duct system (e.g., registers, grilles, boots, air handler, coil, plenums, duct material) " R-2.8 W' thick insulation) for linesets 1" and less. Contractor (Documentation Author's /Responsible Designer'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 California Business and Professions Code to accept responsibility for the information on this document. 3. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the requirements of Title 24, Parts 1 and 6 of the California Code of Regulations (CCR). 4. 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 CCR. 5. 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, Responsible Designer Narnei 4 Responsible Desi ignatur ot�S' d:�^ ucensr�: , ,/ f 'YAkIS a - `T i�J S4 Address: liL Phone: 2,01 & For assistance or 4destions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300 From: Marianne Nouskajian mariannesinteriors@yahoo.com Subject: Mechelke ®ate: June 12, 2019 at 11:14 AM To: Marianne Nouskajian mariannesinteriors@yahoo.com Advanced Distributor Products Grenada. MS 38901 T0356360175B2222AP r� Titf 4 4 0964 P.O. BOX 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLS 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 ,TMPO,R TANTI NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a buildin9 13cmt bassu�?nu din your name listing yourself as the builder of the property improvement, specified at - -7 ten 1F C U X Dr. We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not Issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S A!QKN0M LEIIGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each statement below to sign6 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 worldng 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. 1 understand building permits an not required to be signed by property owners unless they are responsible for the construction and arc not hiring a licensed Contractor to assume this responsibility. 3. l understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect ruyseif from pot=tial financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 14 U_4. I understand Contractors are required bylaw to be licensed and bonded in California and to list their license numbers on perrruts and contracts. �,5. 1 tfnderstand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at ]cast five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. C)--P--" 6. I understand if I am considered an "emaployer" under state and federal law, I must register with the state and federal goverrtmcnt, withhold payroll taxes, provide workers' corgxusation disability insumce, and Contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial dsk• - I understand under California Contractors' Slate License Law, an Owner -Builder who builds single-Farniiy residential structures cannot legally build them with the intent to offer them for sale, purless 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 perforrned tender contract with a licensed general building Contractor. Ct8; I understand as an Owner -Builder if I sell the ro p party for which this permit is issued, I may be held liable for any cial or personal injuries sustained by any subsequent owner(s) that result from any latest construction defeats in the workmanship or Materials. �9. I understand I may obtain more information regarding my obligations as an "employee, from the Internal Revenue Service, the United States Small Business Administration, the California, Department of Benefit Payments, and the California Division of Industrial Accidents. I also unrlagrp-„n„a I MaY contact the California Contractors, State License Board (CSLB) at I- 800-321-CSLB (2752) or www.cstb.ra.gov for more information about licensed contractors. D--- 10. I am aware of and consent to an Owncr-Builder building permit applied for in name and Ply legally and fin..ancizii onsiblc for understand that I am the construction acfiivity at the following address: �i 1. I agree that, as the party legally and Forum ally responsible for this proposed construction a $PPltcabla pates and requirement$ that gavera Owner -Builders as well as employers. activity, I will stride by all C,)�12. I agree to notify the issuer of this form immediately of any additions, deletions or changes tO have provided on this form Liccmed contractors are regulated by laws designed to a public. of theinformationwith I someone who dots not have s lie � protect the public. � you contact with cx>se, the Contractors' State License Board may be vmable to assist you with any ftn=ial loss you may sustain as a result of is eor nplaiat, 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 en3ployee of that individual or firm is injured whole 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 n building permit MR be issued, this form trust be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: r! copy of the property owner's driver's license, form notarinWon, or Other verification acceptable to the ,agency is required to be presennted when thePermit is issued to verify. the property Owner's signature, CSignature of property owner Date: p 'Ltl �j Note: The folloWng.4uthorizatiorr Form is required to be completed by the pro apert3, wner only when desiing gnat an agent of the property owner to apply for a Construction permit for the Owner, -Builder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S gEAd i •F Excluding the Notice to Property owner, the execution of which I understand is m the following penon(s to act as Y P °�responsibility, I hereby authorize Permit for m ) agcnas) to apply for. sign, and 61e the docwnen necessary to obtain an Owner_Builder Y Project � J Scope of Construction Project (or Description of Work): r i 5P. i Project Location or Address: �,}7� 1 7 0tl4BI'IC/�A, Dr, L•� ��� a CW Name of Authorized Agent: t 1 A rl -� K r7e, A149144 k2 i 12 y,l ,L Tel No Address of Authorized Agent: 7 %�7�� A n't F & t( el r I declare under penalty of perjury that I am the property owner for the address listed above and I information and PP P o y tilled out the above certify its accuracy. Note:.4 ca Ofthe v"er's driver's license, form natarixatiox, or other ve J'eation acceptable to the agency is required to be presented when the permit is issued to verify the property owner'i 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 rrmt has een rni� in your name listing yourself as the builder of the property improvements specified at - -7�Q & ��f.11A_ Dr. We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DI C' fnNS: Read and initial each statement below to signs you understand or ventry this information. 4&11 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. 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 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 ann y roperty. 2. I understand building permits are not required to be signed by property owners unless they are responsible for the Jconstru tion and are not hiring a licensed Contractor to assume this responsibility. . i. 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 ❑wn. 4. 1 understand Contractors are required by law to be Iicensed and bonded in California and to list their license numbers on permi and contracts. 5. I understand if I employ or otherwise engage any persons, other than California Iicensed 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 me to serious financial risskk.� LI\ 7. T understand under California Contractors' State License Law, an Owner -Builder who builds sin le-famiI g y 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 nancial 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- S00- 21-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: �x 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all app1iealble laws and requirements that govern Owner -Builders as.well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with snmenne_. who rives not have a license the Contractors' State License Board mar be iinahle to assist yrni unth a•y 1 2nrial ing� you may sustai^ 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. Nate: 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 verb 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 permit far 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. J Scope of Construction Project (or Description of Work): v �) 5 e opolg , "� / �� 1po r, %, 7 e bi n e,�, bl,zei�s Project Location or Address: _ _4q — 7 06 C 04 L' `1elh Dr. Z'A mold a p %r �' %4 53 Name of Authorized Agent: KA rl ?/f n e, i v iw I R Yf Tel No C X&7/ z 3 1 Address of Authorized Agent: III/07T a G1 r: `/� wln7 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 r d to be . resented when the permit is issued to verify the property owners signature. Property Owner's Signature: �t �"�'"�^' t'�-t�'�'" Date: