The URL can be used to link to this page

15080228i�� CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 945 NOVEMBER DR CONTRACTOR: MARTIN AND GAIL PERMIT NO: 15080228 NORDBY OWNER'S NAME: MARTIN AND GAIL NORDBY 945 NOVEMBER DR DATE ISSUED: 10/29/2015 OWNER'S PHONE: 4084993069 CUPERTINO, CA 95014-4120 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ® COMMERCIAL License Class Lie, # CONSTRUCT ONE STORY ADDITION (194 SQ FT); COVERED PORCH (13 SQ FT); KITCHEN REMODEL (100 SQ FT); REMODEL OTHER (385 SQ FT); Contractor Date REROOF (2131 SQ FT); (1) SKYLIGHT. I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $80000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 36213042.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS F LED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs; and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will compl s Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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, usiness & Professions Code) 11 as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupe lino M nicipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 Labor Code, for the the for this the Health & Safety Code, Sections 5 5, , and 25534. 7 of the � performance of work which Owner or authorized agent: ermit is issued. .Date: 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 Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked.. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name! APPLICANT CERTIFICATION Lender's Address 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. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Addi Tonally, the applicant understands and will comply with all non -point spurce a lations per the Cupertino Municipal Code, Section Licensed Professional i� �� Date) Signature E xggl ll CONSTRUCTION PERMIT APPLIC; COMMUNITY DEVELOPMENT DEPARTMENT - BUIL 10300 TORRE AVENUE - CUPERTINO, CA 95014-32 : 55 (408) 777-3228 - FAX (408) 777-3333 - buildinqLaftu ettino.ora ONEW CONSTRUCTION AT)T)TTTnV M A T 7"CD ArTf'ITT / - 71 ORIGINAL PERMIT PROJECT ADDRESS N, APN Y17 - OWNERNAMIE N' 6 A, (_ `Op.-wl PHONE L( 08-�qc('- JkJ Z STREET ADDRESS 9 LJ,3 CITY, STATE, ZI<U.Pr-'e'-T' No, <A, FAX CONTACT NAME NE STREETADDRESSfk CITY, STATE, Zt FAX r-1 OWNER Cl. OWNER -BUILDER. *I-YNERAGENT ❑ CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT ENGINTER 11 DEVELOPER. ❑ TENANT CONTRACTORNAME LICENSENU1,413FR. LICENSETYPE I BUS. LIC 9 b0l,IPANTYNANM E-MAILAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE SE NUMBER BUS. LIC 9 COMPANY NANT3 JPA11 E-MAIL FAX STREET ADDRESS CrIy' STATE, ZIP 6k ILL DESCRIPTION OF WORK ,"S F Lrvivc Ir' -TE 4K 1- C' KxTCik-"4J br,0cttA; R&I-IoUkt, C_vvr,- L& ab f-',ZCq; rcy,67 Atie l. AsOl-Alci E)aSTINGusE PROPOSED USE SFT> C TR E 4 STORIES U� . F TYPE OCC. SQ.FT. VALUATION (S) FD[IST AP-EA01 �1.5 NEW FLOOR AREA f 1-741 DEMO 1 AREA TOTAL NET AREA ve BATHROOM REMODEL AREA C) KITCHEN OTHER REMODEL AREA 11QQ2 REMODEL AREA POR CHARFA DECK AREA TOTAL DECK/PORCH AREA GA GEAREA: ODETACH ATTACH ID 13 9 DWELLING UNITS: IS A SECOND UNIT LJYES SECOND STORY E]YES .1 BEING ADDED? 19 TO 0 ADDITION' PRE -APPLICATION IF YES, PROVIDE PLANNING APPL jf:�P'�S PLANNING APPROCV:C)AI'LYLOF ETI'Ell is THE BLDG AN []'YES ICHLERHONIE? ATO N TOTAL VALUATION; VN� By my signature below, I certify foil wi, am the property owner or authorized ageq�ntto act on the property owner's behalf. Thave reacithis y �id information ItoaeacJioNfth have i application and the infor: , is ha,,e read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating -to b, on I authorize representatives of Cupertino to enter the abo e-idIntified property for inspection purposes. W, S i giature of Appl icanW Date: SUPPLEMENTAL INFORMATION QUIRED @ A -I 2\Tew SFD or Multifamily d«,ellings: Apply for demolition permit for ❑-OYER�-T=COITh PRF gi E existing buildings). Demolition permit is required prior to issuance of building permit for new building --T 15�LAI�'R'LTvG.PLAYSEW - _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Torm if any Hazardous Materials are being used as part of this project. Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. . .. . . . . . ... ls- 'ERO WZ-AMI Bldg.4pp_�201 1. doc revised 06121111 CITY OF CUPERT FEE ESTIMATOR BUILDI ADDRESS: 945 NOVEMBER DR DATE: Q QAPN: BP#: *PERMIT TYPE: Building Permit PLAN CHECK T PRIMARY SFD or Duplex 2nd Unit? Yes USE:OTC? Yes ATO G DIVISION 31/2015 REVIEWED BY: SEAN *VALUATION: $80,000 Addition No PENTAMATION 1 R3SF®ADD G No PERMIT TYPE: WORK CONSTRUCT ONE STORY ADDITION 194 SQ FT • COVERED PORCH 13 SQ FT KITCHEN SCOPE REMODEL (100 SQ FT); REMODEL OTHER (385 SQ FT) REROOF (2131 SQ FT); (1) SKYLIGHT. OCCUPANCY TYPE: TYPE OF CONSTR. R FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) 11-8,111-B,IV,V-B 207 $1,0,91.00 IADDPLCK $1,057.00 IADDINSP $0.00 PME Plan Check: $0.00 385 s f $503.00 Remodel, Other 1REMRESOTH Permit Fee: $1,057.00 Suppl. Insp. Fee:E) Reg. 0 OT FO.O hrs $0.00 F2131 s.f. Re -roof $374.00 IREROOFRES PME Unit Fee: $0.00 PME Permit Fee: $0.00 # Skylight $431.0b 1SKYL<10SF <= 10 s. f. TOTALS: 207 $1,0;91 00 $1,057.00. " MECH, HOURLY Yep 0Nn , I'IlI7MB; HOV2tiX ., . (`' Y-� N ` ELE, HOIl7I2Ir ..; 1`''es • .No . Mech. PIr€Yr f.'h�c'k Phwtb. Plan C Cried l:iec..f'!ut Check ,Ifech. Fenian Fe: Pl'trmb. Permit fi-ev: Alec. Fermi, Fee 07her .Wec h, lruo. other Plumb 7rlq.rF Elce. Absyn Mech. Irxt . I <e: I Plumb. Invp. Fee: � Elec. In-111 Fee: NOTE: This estimate does not include fees due to other Departments (L e. Planning; Public Works, Fire, Sanitary Sewer District, School Dhtrirtt Ptr_)_ Thoao foot nro &ncvd ns. oLn nD...,.. .,F s:,, ,.dl,.l.l.. .. ,7 .. .. 1.. i+_ a_ r. _a.a_,n e__X_ FEE ITEMS (Fee Resolution 11-053 Ef . 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $1,091.00 100 sf. $645.00, Remodel, Kitchen (<=300 sf) IREMRESKIT Suppl. PC Fee: Reg. Cl OT 0.0 hrs $0.00 PME Plan Check: $0.00 385 s f $503.00 Remodel, Other 1REMRESOTH Permit Fee: $1,057.00 Suppl. Insp. Fee:E) Reg. 0 OT FO.O hrs $0.00 F2131 s.f. Re -roof $374.00 IREROOFRES PME Unit Fee: $0.00 PME Permit Fee: $0.00 # Skylight $431.0b 1SKYL<10SF <= 10 s. f. Construction I`ax: r16nini,strative IF'ee. Work Without Permit? Ci Yes (j) No $0.00 Advanced Planning Fee: IPLLONGR $28.98 Select a Non -Residential Building or Structure Trzn,£=i Documenlenhrr,Fc'c's: Strong Motion Fee: 1BSEISMICR $10.40 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $4.00 „ su�ToALs $2,191.38 $1, 953.00 Tt)TAI, FEES' $4,144.38 Revised: 07/02/2015 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: I �/1'nL"t�� 0 �1 Signature D to Please check applicable subcontractors and complete the f ing information: V SUBCONTRACTOR BUSIN NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical 000, Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner /kontractor Signature -� 2—m ow �=-� CUPERTINO Address i1 q S SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(acupertino.org 6 b o%oaA PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE HAS BEEN SIGNED AND RETURNED TO THE BUILDING DIVISION PURPOSE This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) X X On every level of a dwelling unit including basements X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section 8314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below. 1 have read and agree to comply with the terms and conditions of this statement Owner (or Owner Agent's) Name: S' nature . .....................------------------- .......... Date: (4S i!6.. Cohtractor Name: / pp��]] Date:/ si lure...... . .... .... . . ............ Lic.# (p.�.l..l.Q1................... ..`... Smoke and CO formdoc revised 03118114 CUPERTINO Owner Name ra WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (4,Q8) 777-3333 - building c0guaertino.org F� Address D Lw 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. ?<No GO to Question 2. 2. //Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom Of form. Npo Go to Question 3. 3. / Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. No Go to Question 4. 4. Is your real properly built and available for use or occupancy on or before January 1,1994? ❑ No ' My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. 5. P)ease check ONE of the following: t property is a single-family residential real property. See Civil Code Section 1101.4. and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8, the current California Plumbing Code and California Green. Building Standards Code, and manufacturer's installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the table on the following page. A. I I Owner or Owner Agent's Signature: X /d1A-,t YkMWAso Date: I 1 a,G11Fn I Upon completing and signing this Certificate, please retum i"t to Building Division in order to final your building permit. SB407 2015.doc revised 08126115 T 11 1 �S21DSJ OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinona cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: le SITE ADDRESS APN BPS 36 Z- l7- o y 2 <S -, OY u zZ� OWNER NAKEMCJ.l-t�$C,AN` (j PW, _ OWNER ADDRESS - DESCRIPTION OF WORK:'O DESCRIPTION TV��o'c'.�''��Jnl�p, 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: Please read and initial each statement below to signify you understand or verify this information.) 1.2. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- r"building permit that erroneously implies that the property owner is providing his or her own labor and material 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 icjuries, I am willfully acting as an Owner -Builder and am aware of the limits of my /*Iance coverage for infaries to workers on my property. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for theonstruction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 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 nu tiers on permits and contracts. . I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the tot I 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. 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 e to serious financial risk. 7. 1 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 eriormed 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 workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 qI understand I may obtain more information regarding my obligations as an "employer" from the Internal e enue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. ► also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or wvnv.cslb.ca.gov for more information about licensed contractors. Ahe 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I party legally and financially responsible for proposed construction activity at the site address listed above. Abyal1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide lt pplicable laws and requirements that govern Owner -Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the tion I have provided on this form. Licensed contractors are regulated bylaws designed to protect the.public. If youcontract 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 irm is injured while working on your property, you maybe 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. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: �^ Lender Address: Before a building permit can be issued, this form st be completed and signed by the property owner and returned to the agency responsible for issuing the ermit. Note: A copy of the property ov✓Hers drivers license, form notarization, or other verification accgpfa f elt�jA city may be required to be presented when the permit is issued to verifv the property owner's siqnature. AAIi✓; Property Owner's Signature: r[% 1 li 11 Date: 11 "it ill 40, J ------------------------------------------------------------- ------ ------------------------------------------------------------------------ (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 property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10