BRES2019-022378-495 CALLE TAMPICO Ce a D Qumm
LA Q�UINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype:
BUILDING RESIDENTIAL/REMODEL
Application Number:
BRES2019-0223
Property Address:
54400 AVENIDA HERRERA
APN:
774251008
Application Description:
PEREZ / [8] WINDOW CHANGEOUT
Property Zoning:
Application Valuation:
$4,200.00
Applicant:
Payan Victor Manuel Perez /Camacho Angelica P D
54400 ave herrera
La quinta, ca 92253 JUL 12 2019
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 7/12/2019
Owner:
Payan Victor Manuel Perez / Camacho Angelica P
54400 ave herrera
La quinta, ca 92253
Contractor:
Payan Victor Manuel Perez / Camacho Angelica P
54400 ave herrera
La quinta, ca 92253
CITY OF LAQUINTR Llc. No.::CONV:140528101254082562
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.::CONV:14Q5281 12 4
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 thel
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
$5
a5 owner of the property, or my employees with wages as their sole
mpBnSation, 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
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
Pntractors' State License Law.).
am exempt under Sec. . B.&P.C. for this reason
M7�_Vllsnw,
..
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097,-Civ. C.).
Lender's Na
Lender's Add
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:
CarrierPolicyNumber:-
certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose
request and for whose benefit work is performed under or pursuant to any permit
issued as a result of this application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is
not commenced within 180 days from date of issuance of such permit, or cessation of
work for 180 days will subject permit to cancellation,
1 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 men ioned roperty for inspection purposes.
I SI�Rpplicant or Agent a
Date: 7/12/2019
Application Number:
BRES2019-0223
Property Address:
54400 AVENIDA HERRERA
APN:
774251008
Application Description.
PEREZ / [81 WINDOW CHANGEOUT
Property Zoning:
Application Valuation:
$4,200.00
Applicant:
Payan Victor Manuel Perez / Camacho Angelica P
54400 ave herrera
La quinta, ca 92253
Owner:
Payan Victor Manuel Perez / Camacho Angelica P
54400 ave herrera
La quinta, ca 92253
Contractor:
Payan Victor Manuel Perez / Camacho Angelica P
54400 ave herrera
La quinta, ca 92253
Llc. No.: :CON V: 140528101254082562
i- i I
Detail: REPLACE [81 WINDOWS LIKE FOR LIKE RETROFIT. PEk 2016 CALIFORNIA BUILDING CODES,
DESCRIPTION
ACCOUNT CITY
AMOUNT
BSAS SB1473 FEE
101-0000-20306 0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:
$1.00
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
SMI - RESIDENTIAL
101-0000-20308
0
$0.55
Total Paid for STRONG MOTION INSTRUMENTATION SMI:
90.55
DESCRIPTION
ACCOUNT
CITY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
DESCRIPTION
ACCOUNT
CITY
AMOUNT
DOOR/WINDOW, RETRO/REPAIR, EA ADDITION 5
101-0000-42400
0
$11.21
DESCRIPTION
ACCOUNT
CITY
AMOUNT
DOOR/WINDOW, RETRO/REPAIR, FIRST 7
101-0000-42400
0
$67.24
DESCRIPTION
ACCOUNT
CITY
AMOUNT
DOOR/WINDOW, RETRO/REPAIR, FIRST 7 PC
101-0000-42600
0
$65.64
Total Paid for WINDOW/SLIDING GLASS DOOR/FENESTRATION: $144.09
Arch/Eng Name:
Address:
City, St, Zip
Telephone:
Email:
State Lic
Property Owner's Name:
Address:
City, ST, Zip
Telephone:
Email:
City Bus Lic:
Construction Type:
Grading:
Bedrooms: I Stories:
New Commercial / Tenant Improvements:
Total Building
Construction Type:
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
Occupancy:
# Units:
Occupancy:
SF
T - 01-1A
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATEI/il;k—BY
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STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
C_EC-CF 1 R-ALT-D5--E (Revised 07117) _
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
Pro'Qd Hama- CAMACHO/PEREZ
This compliance document is only applicable to
with a HERS Provider Data Registry.
not require HERS
FORNIA
06/18/2019
is required, a CFIR-ALT-01 shall firs t
R-ALT-05-E
Page 1 of 4
Alterations to Space Conditioning Systems that are exempt from HERS verification requirements may use the CFIR-ALT-05 and CFIR-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
HENS Rater. if space conditioning systems ore altered and are not exempt from HERS verification, then a CFIR•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 I.5 to less than 2.5 pounds per cubic foot having an R-value other than 5.8 per inch, or Open Cell Spray
Polyurethane Foam (ocSPF) with a density of 0.4 to less than 1.5 pounds per cubic foot having on R-value of 3.6 per inch, shall complete and register a CF1 R-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:
03
Project Location:
05
CA City:
07
Zip Code:
09
Climate Zone:
11
Building Type:
CAMACHO/PEREZ
q0 j-R4ZAVENIDA HERRERA
LA QUINTA
92253
15
Single Family
02 Date Prepared: 06/18/2019
04 Building Front Orientation (deg or cardinal): WEST
06 Number of Altered Dwelling Units:
08 Fuel Type: Electricity
10 Total Conditioned Floor Area (ft2):
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 July 2017
STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CEC-CF I R-ALT-05-E (Revised 07117)
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
vrolccc namr- MACHO/PEREZ
F. Fenestration/Glazing Proposed Areas and Efficiencies - Replace (Section 150.2(b)16)
01
+ 02
03
' 04
05
06
07
Area
Area
Fenestration
Dynamic
Orientation
Removed
Added
Tag/ID
Type
Frame Type
Glazing
(N, S, W, €)
(ftz)
(ftz)
1
Operable
Non-metal
West
1
0
0
2
Operable
Non-metal
South
0
0
3
Operable
Non-metal
South
0
0
4
Operable
Non-metal
East
0
0
5
I
Operable
Non-metal
North
0
0
6
Operable
Non-metal
North
0
0
7
Operable
Non-metal
North
0
0
8
Operable
Non-metal
East
0
0
__FAdd Row Delete Row
15 Net Added West -facing Fenestration Area
16 Is Net Added Fenestration Area 5 for west -facing fenestration?
17 Net Added Fenestration Area (all orientations)
08
09
10
Net
Added
Area (ftz)
U-factor
Source
0
0.30
NFRC
0
0.30
NFRC
0
0.30
NFRC
0
0.30
NFRC
0
0.30
NFRC
0
0.30
NFRC
0
0.30
NFRC
0
0.30
NFRC
1111 Yes (7 No
CALIFORNIA
06/18/2019
COMMISSION
CF1R-ALT-05-E
Page 2 of 4
11
12
13
14
Combined
Exterior
SHGC from
SHGC
Source
Shading Device
CF1R-ENV-03
0.22
NFRC
0.22
NFRC
0.22
NFRC
0.22
NFRC
0.22
NFRC
0.22
NFRC
0.22
NFRC
0.22
NFRC
CA Building Energy Efficiency Standards - 2016 Residential Compliance July 2017
STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CEC-CF1 R-ALT-ME (Revised OW17)
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CAMACHO/PEREZ
CA Building Energy Efficiency Standards - 201 -Residential Compliance
06/18/2019
CF3
Page 3 of 4
July 2017
STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CEC-CFI R-ALT-05-E (Revised 0711 T) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R-ALT-05-E
Prescriptive Residential Alterations That Do Not Require HERS Field Verification Page 4 of 4
P�oiecr Nsme' CAMACHO/PEREZ Da:c Prep+m!•
06/18/2019
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
1. I certify that tilis Certificate of Compliance documentation is accurate and complete.
Do[umen[ation Author Name: CHARLOTTE DAS Documentation Author Signature:
Company: gSinature Date:
WINDOW WORLD OF RIVERSIDE COUNTY 06/18/2019
Address: CW HERS Certification Identificatfon fif appricable):
11671 STERLING AVE., UNIT D/E
C tyJStatsJp: Rhone:
RIVERSIDE,CA 92503 951-354-2723
RESPONSIBLE PERSON'S DECLARATION STATEMENT
1 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 builder provides to the building
owner at occupancy.
Responsible Designer Name: Responsible Designer 5ignature:
CHARLOTTE DAS I
Company!DateSigned: WINDOW WORLD OF RIVERSIDE COUNTY 06118/2019
Address: ticenie:
11671 STERLING AVE., UNIT D/E 1018007
RIVERSIDE,CA 92503
951-354-2723
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
July 2017
CITY OF LA QUINTA SUB -CONTRACTOR, LIST
JOB ADDRESSM 401 PERMIT NUMBER OWNER f a BUILDER
This form shall be aosted on the job with the Building Inspection Card at all times in a cons icuo s face. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each aDDlicable trade, all information requested below must be completed by anolicant. "On File" is not an acceptable response.
. _Tradeej.Clas.si.fic-ation.
Contractor- .....
State Contractor's License
Workers Compensation -Insurance
. Gity.Bus.:iness. License.
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/),x/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
CONCRETE (C-8)
FRAMING (C-5)
STRUCT. STEEL (C-S1)
M.ASO.NRY (C-2:9).
-
PLUMBING (C-36)
LATH, PLASTER (C-35)
DRYWALL (G=9)
HVAG iC-20)
ELECTRICAL (C-10):
ROOFING (C-39)
SHEET:METAL (C-43)-
FLOORING (C-15)
GLAZING (:C-17)
INSULATION (C-2)
l�
V��/�lJ`ei�
�%L✓ �l.
�G
.01
.SEWAGE. DISP ,(C-42)
PAINTING. (C-33)
CERAMIC TILE: (C-54:)
CABINETS (:C-6)
.FENCING (C=13)
LANDSCAPING (:C-27)
=POOL-53)
STATE OF C-A L I F O R N I A
CONTRACTORS STATE LICENSE BOARD
Pursuant to Chapter 9 of Division 3 of the Business and Professions Code
and the Rules and Regulations of the Contractors State License Board,
the Registrar of Contractors does hereby issue this license to:
00014 PLC
dha WINS)NOKObF,RIVE.-.1-. COUNTY
� 7
.,License Numbir 101
is .i�•`;: -
to engage in tho business-o act in -the: apacit 64 ctirj�r�a�;i,� the fOklawirlg slassiticatians:
C 17 - GtJ,�1
b28Fti�ti:-GATES-A'�Ek��►'-A �,b�VICEi
7�
11ll ssffiyrl 6d and sea! this dam`
mber.s .
Mario Richardson, Board Chair This license is the property of the Registrar or Contractors, David R. Fogt, Registrar of Contractors
is nottransferable, and shall be returned to the Registrar
upon demand when suspended, revoked, or invalidated
for any reason. it becomes void N not renewed.
13L-24 (REV. 10/17) WIM 08P 1714SW
AUDIT NO: 970747
BUSINESS LICENSE
CERTIFICATE
NON -TRANSFERABLE
BUSINESS LOCATION
OUTSIDE CITY LIMITS
1 f.
W
GEM a/& DESERT �—
78-495 Calle Tampico La Quinta,'California 92253
(760)777-7000
BUSINESS NAME: WINDOW WORLD OF RIVERSIDE COUNTY
MAILING ADDRESS: 11671 STERLING AVENUE - UNIT D
RIVERSIDE, CA 92503
By
DESIGN AND DEVELOPMENT DIRECTOR
Dear Business Owner:
Please be aware that issuance of a business license by the City does not authorize you
to conduct business in a building or tenant space that has not been approved for
occupancy by the Design and Development Department. If you have any questions
regarding this issue, or if you are not sure if a Certificate of Occupancy has been issued
for your place of business, please contact Design and Development at (760)777-7000.
The Licensee named herein having paid to the City of La Quinta all fees required,
license is hereby granted said licensee to transact the business herein set forth, for the
period stated, in conformity with the Provisions of Ordinance No. 2 of this City. This
Licensee is issued without verfication that the licensee is subject to or exempt from
licensing by the State of California.
BUSINESS LIC NO: LIC-765791
CLASSIFICATION: SUB CONTRACTOR
EXPIRATION DATE: 4/30/2020
Window Sizes
IN
SHGC: 0/.22
U-Factor: U,2,r)
11
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IZ
Tityl 4 4a«!x1a
P.O. BOX 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision,
signed, and returned this 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.
kuuLl. 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 willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my property.
Y" 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.
1
t' 11 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.
. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
pe rnits and contracts.
y
�C 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.
rovern
. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
ment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
�7. I understand under California Contractors' State License 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.
IC8. 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
workmanship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-
80Q 321-CSLB (2752) or www.cslb_ca.gov for more information about licensed contractors.
I Ol I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
arty legally and financially responsible for proposed construction activity at the following address:
el . I agree that, as the a legally and financially responsible for this proposed construction activity, I will abide b all
g party g Y Y P P P h'� Y"
applicable laws and requirements that govern Owner -Builders as well as employers.
cu
6 �— 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. 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 the agency is required to be presented when the permit is issued to verify the property
owner's signature.
f� f
Signature of property ownerr),fl_� `�' - {.(� Date: _7
Note: The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO 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:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above
information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification
acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature.
Property Owner's Signature: _ Date: