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14010021 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10011 N FOOTHILL BLVD STE 101 CONTRACTOR:MI ELECTRIC INC PERMIT NO: 14010021 OWNER'S NAME: KAPILA KAVITA AND ANIL 5255STEVENS CREEK BLVD DATE ISSUED:06/17/2014 OWNER'S PHONE: 4087491050 SANTA CLARA,CA 95051 PHONE NO:(408)366-0100 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL (� COMM T.I REMODEL INTERIOR SPACE FOR DENTAL License Class s i.�/y Lic.# PC/5G-9 OFFICE Contractor / Date _% 808 SQ FT TO INCLUDE M,E,P'S �,� _ � I hereby affirm that I am licens d 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. 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$18000 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor�C Code,for the performance of the work for which this ermit is issued. APN Number:34249024.00 Occupancy Type: APPLICANT CERTIFICATION 1 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 WITHIN DAY?OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY ROM LAST CALLED 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 comply Issued by: Date: 67 with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature t �� Date - �� 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 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,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 or 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 Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:/ZI-"� Z Date: 6� permit is issued. 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 Worker's Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY 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 pen-nit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Date i CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION t1b� 1 \v 10300 TORRE AVENUE•CUPERTINO, C!+•95014-3255 A� (408)777-3228• FAX(408) 777-3333• buildings gP99 no.or CUPERTINO ; ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION!TI ❑ REVISION!DEFERRED ORIGINAL PERMIT# PROTECTADDRESS10011 N FOOTHILL BLVD, 101 APN4 342-49-024 OWNER NAMF. ANIL KAPILA 1 7rl4A]LPHoxE 408-749-1050 anil_kapila@yahoo.com STREET ADDRESS 10011 N FOOTHILL BLVD. 101 CITY. STATE.ZIP CUPERTINO.CA 95014 FAX CONT u T \AMF ANIL KAPILA PHONT 408-749-1050 F-1IAn. anil_kapila@yahoo.com STRFF:r aDDRFSS 10011 N FOOTHILL BLVD. 101 ; rl rY sT ATF. nr CUPERTINO,CA 95014 FAX OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DE-,ELOPER ❑ TENANT U)NZRAC LUR\AV1L KEE HWANG LICLNSL NLNIBLR 801498 LICE:Ise r)PE HLs LIC a B.C-10 COMPANY NAME MI ELECTRIC INC EdtAu_ mielectric@gmail.ccm IAX STRE.ETADDRESS 2510 OLD MIDDLEFIELD WY,#1 CITY,STA-IE,ZIP MOUNTAIN VIEW.CA 94043 PHONE 408-366-0100 ARCHITEC'T/ENGMER NAME LICENSE NUMBER BUS.LIC u COMPANY NAME E-MAIL FAX STRF.F:I'ADDRESS CITY.STATE,ZIP PHONE OEcTRrPTIOV Or WORK TI FOR DENTAL OFFICE EXISTING UE PROPOSED 1."SF CONSTR TYPE t STORIES MEDICAL MEDICAL 1 USE TYPE uc('. St1Ft. AALL AIIWI(A, FNISTO 808 SFT NFWFLOOR U Ato 0 TUT.)L 808 SFT ARLA AREA 808 SFT AREA NET AREA H..........I 25 SFT 1.lT('H F.;� 1)'rHER REMODEL ARL,,, REMODEL AREA REMODEL AREA POR(41 iRF_t f)FCIi aRF 1 71)T AL D@("K P(IRCH AREA tiARAriE ARF,A DE'rA('11 AT'I A('H U WFLLR( I KII S IS A SECOND I.NIT ❑Y I.S SECOND STORY ❑YEN C]NO ADDITION ❑NO PRE-APPLI(ATION OYES IF Y ES.PROA IDE COPi OF IS THE BLDG AN ❑YES REC'.F.IYL Tf)TAL dLI-All ION. PLANNNG APPL b ❑NO PLANNING APPROVAL IErrrR EICHLER HOME? ❑NO Bymy signature below,J certi6 to each of the following: I am the property owner or authorized agent to act on the property owner's behalf, f have read this application and the inlbrmation I have provided is correct I hae read the Description of Work and verify it IS accurate I agree to comph with all applicable local ordinances and state laws relating to building constructlol I authorize representatives of Cupertino to enter the above-identified01/06/2014ed propertl for Inspection purposes. ` Sionatureol AppllcanliAr�ent Date: SUPPLE•MENTAI.INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building El oA'ER-rHt;t'DrNTFR DrKr,PL-AN Rf►TE►A permit for new building. ECPREss TANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS R)tm if an} Hazardous Materials are being used as pall of this pro,ject. ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to [] MAJOR S.ANITARX SEA}'ER DIS'fRIC'f submittal of Building Permit application. ❑ FNWIRONMENTAL HEALTH Bldg.app_2011-doc revised 00_71 1 r I CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ?0300 TORRE AVENUE•CUPERTINO, CA 95014-3255 1 (408)777-3228•FAX(408)777-3333• buildinq(@r-upertino.org CUPERTINO ❑NEW CONSTRUCTION ❑ ADwriON [)}ALTERATION/T1 ❑ REVISION!DEFERRED ORIGINAL PERMIT# PRotELTADDRESs10011 N FOOTHILL BLVD, 101 7A4 342-49-024 OWNER NAME ANIL KAPILA PHONE 408-749-1050 g MAIL anil_kapila@yahoo.com eTRFFT 1nnRFGS 10011 N FOOTHILL BLVD, 101 CITY. STATE.ZIP CUPERTINO, CA 95014 FAX i CONTACT NAME ANIL KAPILA PHONE 408-749-1050 E-ntAll, and_kapi[a@yahoo,corn ;,,TREEr AnDRESS 10011 N FOOTHILL BLVD, 101 71P CUPERTINO,CA 95014 FAX Ld OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DE\ELOPER ❑TE'NAN I (O\-TRACTOR-,'AME KEE HVVANG LICENSE NUStBER 801498 LlcrNsL TYPE BLAS LIC 4 B, C-10 COMPANY NAME MI ELECTRIC INC E-MAIL miefectric@gmaii.com FAX STRFLF ADDRESS 2510 OLD MIDDLEFIELD WY,#1 crn°,STATE,zip MOUNTAIN VIEW, CA 94043 PHONE 408-366-0100 ARCHRECTXNGINEER NAME- LICENSE NUMBER BUS.LIC k COMPANY NAME E-NIAI. FAX STRFFT ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK TI FOR DENTAL OFFICE EXISTf^:G I'SE PROPOSED L SF CDN51R TYPE k STORIES MEDICAL MEDICAL 1 1 USE rYPE OCC. SQ.F-t. sALU I1n-�tr; EXISTG 808 SFT NT.W FLOOR D1:StU 0 T(YIA�L 80$SFT AREA AREA 808 SFT AAEA \LT AREA n+nlRr1r1n1 Arr['rlrt r>f"HFR REMODEL AREA 25 SFT REMUDL•L AREA RLMUOEL AREA PORCH AREA DFUA AREA TOTAL DIrCK POR('II AREA GARAGEAREA DCTACII _--ATTACH -'--- sBWEI-Lr.' C1I:IT5 IS ASECOtiD l:\lT ❑tl:ti SECOYD STORY ❑YES BEINGADDED' [3NO ADDITION? ONO PRE-APPLICAT10% [IVES IF YES.PRO%IDE COPY OF IS THE BLDG AN ❑t'Es RECUVED BY, TOTAL ALUATIO`. PLANNING APPL 4 []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my sienalure below;1 certify to each of the following: t am the property owner or authorized agent to act on the property owner's behalf .1 have read this application and the information t have provided is correct. I ha%e read the Description ol-Work and verify it is aAxurate. 1 agree to complN with all applicable focal ordinances and state laws relating to building construction. 1 thorize representatives of Cupertino to enter the above-Identified property for inspection purposes. Signature of,ApplicanuAgent. Date: 01/06/2014 SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BlT,I)ING PLAN RHl9EN� existing building(s). Demolition permit is requited prior to issuance of building permit for new building. ❑ FxmEss ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as pail of this project. ❑ LARGE ❑ FIREDEPT __Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑ NLA.IOR ❑ SANITARY SEA'ER DIS"1"RI('T ❑ F.1\17RON11ENTALHEALTH Bl(ffiOpp_2011.doc revised 06 2/ 11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10011 N Foothill blvd 101 DATE: 01/06/2014 REVIEWED BY: Mendez APN: BP#: 49/00pZ_/ "VALUATION: 1$18,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION 1B 1-1 USE: PERMIT TYPE: WORK comm t.i remodel interiors ace for dental office 808 sq ft to include m e 's SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s1. B (1-enant Improvements) II-B,III-B,WN-B 808 $2,066.66 IBTIPLNCK $969.22 IBTIINSP TOTALS: F 808 1 $2,066.66 1 $969.22 MECH,HOURLY 0 Yes 0 No PLUMB,HOURLY Q Yes No PLEC,HOURLY 0 Yes 0 No )t't�i 1!c-c°�i. lr��> ;s,l c. .'xr .�,I.: /),�, �•!;<__I�as�, I:n,"1°��c: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etG). Thesefees are based on the prelimina information available and are only an estimate Contact the Dept for addn'1 info, FEE ITEMS (Fee Resolution 11-053 Eff L/1113 FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,066.66 Select a Misc Bldg/Structure Suppl. PC Fee: E) Reg. 0 OTF6-.61 h r s $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $969.22 Suppl. Insp. Fee:Q Reg. 0 OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 i 't'mslrucfion TV'L ;1c1e;l,iur`. rrr�ri.c Fcc: 0 Work Without Permit? 0 Yes (E) No $0.00 0 Advanced Planning Fee: $0.00 Select a Non-Residential I%1 7 1-avel 0ocim''levoli"m Fcl-"s. I Building or Structure 0 i Strong Motion Fee: 1BSEISMICo $3.78 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $3,040.66 $0.00 TOTAL FEE: $3,040.66 Revised: 10/01/2013 S4,)— Building td.ZBuilding Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U PERTI Fax: 408-777-3333 0 )CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: /vc// tj .74m-&X1 A A J PERMIT# OWNER'S NAME: PHONE# GENERAL CONTRACT R: ( .� BUSINESS LICENSE# ADDRESS: a j '.� /Jai CITY/ZIPCODE: *Our municipal code requires al is i cas es k ity 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: �� /` Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical A Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry (/ Painting/Wallpaper Paving Plastering tf Plumbing Roofing Septic Tank Sheet Metal v Sheet Rock Tile Owner Contractor Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P ERTI N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 1'C o 11 N. P,4-AL Blvd S)--)- 1 PERMIT# JLD I C)0 Z OWNER'S NAME: KAv� 'f A A P1 L A PHONE# S1 '7-7 '1 L-1 % 26 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *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 amusing any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: j/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical 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 Ae Owner/Contractor Signature Date r OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTI N0 (408)777-3228• FAX(408)777-3333• building aalcuoeriino.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: SITE ADDRESS 1 O 0 11 N • `=o o i ` S 6\.rci , APN � ofo c; jc { � j 4 9 ` aLy o v �I OWNER NAME I OWNER ADDRESS rj 6 2 E, ,A-4', 1-AP1L A DESCRIPTION OF WORK: pA;,t 0_1 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. 1 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 on my property. a '"--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. CqY" 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. '/1"4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. ✓►��5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"under state and federal law. l 9 �. 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. r ,9 -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 performed under contract with a licensed general building Contractor. (C) ' 8 1 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. 0w77e7Bid1de1F07771 2010.doe revised 09/19/10 (C- - 9. 1 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 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. � -)Co. 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 construction activity at the site address listed above. 9i±71. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. Cq::�=-r. 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 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. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the foliowing construction lending agency information.) 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 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 city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: I C2 vl --------------------------------------------------------------------------------------------------------------------------- ------- - (NOTE: The following Authorization Form is required to be completed by the property owner only when designati------ -- ng 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: Tel No Address of Authorized Agent: declare under penalty of perjury that l 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: Oi4�ne7BuilderFo7-7n 2010.doc revised 04114110