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BRES2020-000378-495 CALLE TAMPICO D 4v LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT Permit Type/Subtype: BUILDING RESIDENTIAL/REMODEL Application Number: BRES2020-0003 Property Address: 55435 TURNBERRY WAY APN: 767550006 Application Description: MORRIS / [3] WINDOW CHANGEOUTS Property Zoning: Application Valuation: $25,000.00 / n Applicant: F JOHNATHAN GONZALEZ 79415 HIGHWAY 111 9-220 JAN 10 2020 LA QUINTA, CA 92252 D 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 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 as is the applicant to a civil penalty or not more than five hundred dollars ($500).: ' I, as owner of the property, or my employees with wages as their sole pensation, 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 ocher 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 or did not build or improve for the purpose of sale.). as owner of the property, am exclusively contracting with licensed contractors to strutt 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 tors' State License Law.). } 1 am exempt under Sec. B.C. fort is r son r, Date: I .w U Owner CONSTRU LE DING 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 Name: Lender's Address: VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 1/10/2020 Owner: MORRIS POLLESEL PALM SPRINGS P 0 BOX 4291 LIVELY ON CANADA P3Y, N3 92253 Contractor: OWNER BUILDER 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: Carrier: _ Policy Number: I 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 at, i I should become s bject to the workers' compensation provisions of Sett,-n370 should Cod Jr shall forthwith complywit those revisions. Date: [ D Zi7 Applican WARNING: FAILURE TO SECURE WORKERS' COM ENSATiON COVERAGE IS U LAWFI AND SHALL SUBJECTAN 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 a ve information is correct. I agree to comply with all city and county ordinances ands to aw ati g to bu ding construction, and hereby authorize representatives of this city a r up he ve mentioned japer y for inspection purposes, Date: I [ 20� Signature (Applicant orAge Date: 1/10/2020 Application Number: BRES2020-0003 Property Address: 55435 TURNBERRY WAY APN: 767550006 Application Description: MORRIS / [3] WINDOW CHANGEOUTS Property Zoning: Application Valuation: $25,000.00 Applicant: JOHNATHAN GONZALEZ 79415 HIGHWAY 111 9-220 LA QUINTA, CA 92252 Detail: [3] WINDOW CHANGEOUTS RETROFIT LIKE FOR LIKE. PER 2019 CALIFORNIA BUILDING CODES. Owner: MORRIS POLLESEL PALM SPRINGS P 0 BOX 4291 LIVELY ON CANADA 133Y, N3 92253 Contractor: OWNER BUILDER Llc. No. INFORMATIONFINANCIAL DESCRIPTION ACCOUNT QTY AMOUNT BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT QTY AMOUNT PLAN CHECK DEPOSIT - ADDITION/REMODEL 101-0000-42600 1 $125.00 Total Paid for PLAN CHECK DEPOSIT - ADDITION/REMODEL: $125.00 DESCRIPTION ACCOUNT QTY AMOUNT RECORDS MANAGEMENT FEE - MAJOR 101-0000-42416 0 $21.00 Total Paid for RECORDS MANAGEMENT FEE - MAJOR: $21.00 DESCRIPTION ACCOUNT QTY AMOUNT SMI - RESIDENTIAL 101-0000-20308 0 $3.25 Total Paid for STRONG MOTION INSTRUMENTATION SMI: $3.25 DESCRIPTION ACCOUNT QTY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 DESCRIPTION ACCOUNT QTY AMOUNT DOOR/WINDOW, RETRO/REPAIR, FIRST 7 101-0000-42400 0 $67.62 DESCRIPTION ACCOUNT QTY AMOUNT DOOR/WINDOW, RETRO/REPAIR, FIRST 7 PC 101-0000-42600 0 $66.01 Total Paid for WINDOW/SLIDING GLASS DOOR/FENESTRATION 2019: $133.63 PERMIT # 01c7-cQ0 PLAN LOCATION: Project Address." �L� �f- Project Description. Pool, Remodel, Add't, Elect, Plumb, Mech APN #: l•. Applieant Name:,, Address: City, ST, Zip: ZZy Telephone: L)C - Email: •• GI r 1[�tiQ O�.P act $ Contractor Name: New SFD Construction: Address: -+ -.. *, Conditioned Space SF City, St, Zip �(�r, 70 Garage SF Telephone: IV _ f • , (�( )c'- Patio/Porch _ , SF Email: Fire Sprinklers SF S e Lic: UJ 1(� City Bus Lic: ft� Arch/Eng Name: Construction Type: 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: 9,c;�N r L Total Building SF City, ST, Zip LIAZ Construction Type: Occupancy: Telephone: Ema ICO LA QU I NTA, CA 92253 760-777-7000 STATE OF CALIFORNIA Prescriptive Residential Alterations That Do Not Require HERS Field Verification CEC-CFIR-ALT-05-E (Revised 01120) CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE Prescriptive Residential Alterations That Do Not Require HERS Field Verification CF1R-ALT-05-E W z0 Page 1 of 4 [with his compliance document is only applicable to simple alterations that do not require HERS verification for compliance. When HERS verification is required, a CFIR-ALT- 01 shall first be registered a HERS Provider Data Registry. Alterations to Space Conditioning Systems that are exempt from HERS verification requirements may use the CFIR-AL T-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 CFIR-ALT-02 must be completed and registered with a HERS Provider Do to Registry. Alterations that utilize close Cell Spray Polyurethane Foam (ccSPF) with a density of 1.5 to less than 2.5 pounds per cubic faot having an R-value greater than 5.8 per inch, or Gpen Cell Spray Polyurethane Foam {oc$PF] 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 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. Temporary labels shall not be removed before verification by the building inspector. i A. General Information 01 Project Name: 03 Project Location: 05 CA City: 07 Zip Code: 09 Climate Zone: 11 1 Building Type: / f ■or i ,5S7V31 02 Date Prepared: 04 Building Front Orientation (deg or cardinal): 06 Number of Altered Dwelling Units: 08 Fuel Type 10 Total Conditioned Floor Area (ft) 12 Slab Area (ft) //9/?vZZ 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 - 2019 Residential Compliance - January 20,20 STATE OF CALIFORNIA Prescriptive Residential Alterations That Do Not Require HERS Field Verification CEC•CF1R-ALT-05-E (Revised 01I20) CALIFORNIA CERTIFICATE OF COMPLIANCE Prescriptive Reside tial Alterations That Do Not Require HERS Field Verification Prolecs Name: Date Prepared: D. Fenestration/Glazing Allowed Areas and Efficiencies (Section 150.2(b)1) 01 02 03 04 05 06 Maximum Maximum Existing Allowed Allowed Fenestration Existing Maximum Maximum Maximum Maximum Fenestration West -Facing for All West -Facing Allowed Allowed Allowed Allowed Alteration for All Fenestration Orientations Fenestration U-Factor U-Factor SHGC SHGC Type Orientations (ftz) _ Area Only (ftz) (ftz) Area (ftz) (Windows) (Skylights) g ) I (Windows) (Skylights) ,MMISSION CF111-ALT-05-E Page 2 of 4 go 07 Comments F. Fenestration/Glazing Proposed Areas and Efficiencies - Replace (Section 150.2(b)1B) Note: Doors with greater than or equal to 25 percentglazed area are considered glazed doors and are treated as fenestration products. 01 02 03 04 05 06 07 08 09 10 11 12 13 14 Area Area Net Proposed Proposed Combined Fenestration Dynamic Orientation Removed Added Added Proposed U-factor Proposed SHGC Exterior SHGC from Tag/ID Type Frame Type Glazing (N, S, W, E) (ftz) (ftz) Area (ftz) U-factor Source SHGC Source Shading Device CF1R-ENV-03 V%Va% (aj Add Row Delete Raw 15 Net Added West -facing Fenestration Area 16 Is Net Added Fenestration Area <_ for west -facing fenestration? r Yes r No 17 Net Added Fenestration Area (all orientations) 0 18 Is Net Added Fenestration Area <_ 0 for all orientations? C Yes r No `J 1 19 Proposed Fenestration U-factor (Windows)��� 20 Required Fenestration U-factor (Windows)] I 21 Is the proposed Fenestration U-factor <_ the Required Fenestration U-factor? r Yes C No 22 Proposed Fenestration SHGC (Windows) 23 Required Fenestration SHGC (Windows) 24 Is the Proposed Fenestration SHGC <_ the Required Fenestration SHGC? r Yes r No CA Building Energy Efficiency Standards - 2019 Residential Compliance January 2020 STATE OF CALIFORNIA Presciriptive Residential Alterations That Do Not Require HERS Field Verification CERTIFICATE OF COMPLIANCE Prescriptive Residential Alterations That Do Not Re ire HER Field Verification profcc% Name: � 7.� Date Papa y 25 Proposed Fenestration U-factor (Skylights) 26 Required Fenestration U-factor (Skylights) 27 Is the proposed Fenestration U-factor <_ the Required Fenestration U-factor? r Yes r No 28 Proposed Fenestration SHGC 29 Required Fenestration SHGC 30 Is the Proposed Fenestration SHGC <_ the Required Fenestration SHGC? Ir` Yes r No CA Building Energy Efficiency Standards - 2019 Residential Compliance MMISSIOM CF1R-ALT-05-E Page 3 of 4 January 2020 OF CALIFORNIA .-.*( riptive Residential Alterations That Do Not Require HERS Field Verification CERTIFICATE OF COMPLIANCE Prescriptive Residential Altera Project Name: s That Do Not Require HERS Field Verification DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Compliance documentation is accurate a —Zzo u r RESPONSIBLE PERSON'S DECLARATION STATEMENT Z,7_9.- 0 ERGY VIVIISSION CF1R-ALT-05-E Page 4 of 4 I certify the fallowing 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 Nanii.iA Company 5 q2- L P Date Q/l3E5 • 7—(7 V For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300. CA Building Energy Efficiency Standards - 2019 Residential Compliance January 2020 P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT (760) 777-70 12 FAX (760) 777-7011 Considering Becoming an Owner -Builder? 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: Highest Benefits 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 Loos 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 Significant 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. BenefiVRisk: Possible 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 include workmanship and workers' compensation issues Homeowners suffer financial harm due to 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. In remains 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 Camp 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 his1her employees? Did you know — if you are considered an "employer" under stake 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 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 MPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been jubbrnat9d in your name listing yourself as the builder of the property improvements specified at We are providing you with an Owner -Builder Ac owle gment Informa on 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 INFORMATIQN 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 q P p 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 rryy property. ,// 2. 1 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. �/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 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permzys 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" undstato and federal law. 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 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. 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 financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the warrnship or materials. 9. 1 understand I may obtLim 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- 800-'�21-CSLB (2752) or www.cslb.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,_ responsible for proposed fonstruction jctivity Aat the following address: I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applic9ble laws and requirements that govern Owner -Builders as well as employers. t//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 darnages. 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 i ' the permit. Note: A copy the property owner's driver's license, form notarization, or other verification acceptable to the is required f e resented when the permit is issued to verify the property owner's signature. Signature of property owner r 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 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. I Scope of Construction Project (or Description of Work): G ra _ r � i n w Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: ` VOT- -# 20 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 it ate: A copy of wrter's driver's license, form notarization, or other verification acceptable to the agency i.s requi ed to pr nt77`7 'the permit is issued to verb the prope ty owns s signature. Property Owner's Signature: Date: r + tY i 1 � 1 _ S w r 77 + 1 CITY OF LA QUINITA BUILDING SAFME DEFT: