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13010163 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21744 REGNART CT CONTRACTOR:ANTAL BRUCE G AND PERMIT NO: 13010163 MAUREEN S OWNER'S NAME: ANTAL BRUCE G AND MAUREEN S 21744 REGNART CT DATE ISSUED:01/31/2013 OWNER'S PHONE: 4082533494 CUPERTINO,CA 95014-4834 PHONE NO: ❑ LICENSED 13 CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB e,v #License Clas&ht.z ' Lic. --9 �ZION-J L j- MECH r RESIDENTIAL r COMMERCIAL Contractor Date lJ I hereby affirm(bat 1 am licensed under the provisions f Chapter 9 JOB DESCRIPTION: KITCHEN REMODEL 225 SQ FT,M.BEDROOM 285 SQ FT, (commencing with Section 7000)of Division 3 of the Business&Professions REMOVE AND REPLACE 18 WINDOWS AND 2 DOORS,REPLACE Code and that my license is in full force and effect. 27 LIGHTS9/25/13-REVN1 -COFFERRED CEILING ISS'D OTC 9/25/13 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 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 Sq.Ft Floor Area: Valuation:$80000 permit is issued. APPLICANT CERTIFICATION APN Number:35624033.00 Occupancy"Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST ALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. x} Issued by: ! r Z� —3ate: Signature Date ❑ OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 Ow r or au horized agent: forthwith comply with such provisions or this permit shall be deemed revoked. Date: CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•buildino cupertino.org CUPERTINO ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION DEFERRED ORIGINAL PERMIT 7016 i PROJECT ADDRESS Z1 7qq 1 n A,—t CT APN# v, 33 OWNER NAME PHONE, -�� E-MAIL STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHONE E-MAIL STREETADDRESS GG( CITY,STATE, ZIP FAX le"qL�,,Iqe, '35,,-70 ❑ OWNER ❑ OWNER-BUILDER Q ONNERAGLNT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# 1 of, -r- Ism+r &G 40 0�:T COMPANY NAME - / E-MAIL / FAX ge>6 10 STREET ADDRESS CITY,STATE,ZIP PHONE /61-1 e l a' CA 4-" 6 r v ) 5 - rt�GiGi ARCHITECT/ENGINEER NAME , LICENSE NUMBER ! BUS.LIC# ff COMPANY NAME E-MAIL FAX - 733, lSy STREET ADDRESS CITY,STATE,ZIP �u PHONE lti1 rt vvlC 7 Sl DESCRIPTION OF GCI EXISTING USE PROPOSED USE CONSTR.TYPE ASTORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODELAREA REMODEL AREA REMODELAREA PORCH AREA DECK AREA TOTAL DECK%PORCH AREA GARAGE AREA: DDETACH ❑ATTACH N DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑No ADDITION? ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECE VED BY: TOTAL VALUATION: PLA\TING APPL# ❑ M ❑NO PLANNING APPROVAL LETTER EICHLER HOE? NO • a.00 , !S- By my signature below,1 certify to each of the following: I am the property owner or authorized agent to ton the property owner's behalf. I have read this application and the information I have provid is orrect. I have read the Description of Work and verify itis accurate. 1 agree to comply with all applicable local ordinances and state laws relating to b ' Ing o tivction uthorize representatives of Cupertino to enter the abov ide tified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTA ORMATION REQUIRED PLAN CHEC TYPE ROUTING SLIP New SFD or Multifamily ellings: Apply for demolition pen-nit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to Submittal Of Building Pel-mit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp_20//.clot revised 06/21/11 CITY OF CUPERTINO ILIFEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21744 Regnart Ct. DATE: 09/25/2013 REVIEWED BY: larrys APN: BP#: ���/ *VALUATION: $200 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK �cofferred ceiling SCOPE Mech. 1'lu; :ck Plumb. Plan Check Llcu.Plan ChLzk Nfech.Perwit Plumb. PermirFlec. Permit Fee: Other Afech.Insp. Other Plumb Insp. Other Elec. Insp. Mech.Insp, Frye: Phturb. hrsp. Fee_ Elcc,Insp. Fee: NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works, Fire,Sanitary Sewer District,School District,etc). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS (Fee Resolulion 11-053 Eff. 7/1/13) FEE QTYIFEE MISC ITEMS Plan Check Fee: Hourly Only? ()Yes Q No $0.00 1 hours Plan Check,Hourly Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 $139.00 ISTPLNCK PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Supp/. Insp. FeeQ Reg. 0 OT Q.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Conswuction Tax: Adininistrative Fee: Select a Non-Residential Q Work Without Permit? 0 Yes E) No $0.00 Building or Structure 0 Advanced Planning,Fee: $0.00 Select a Non-Residential E) Tr ai el Documentation Fees: Building or Structure 0 A Strom Motion Fee: IBSEISMICR $0.50 1.0 hrs Inspections Bldg Stds Commission Fee: IBCBSC $1.00 $139.00 ISTINSP 7Inspection,Hourly SUBTOTALS: $1.50 $278.00 TOTAL FEE: $279.50 Revised: 08/01/2013 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21744 REGNART CT CONTRACTOR:ANTAL BRUCE G AND PERMIT NO: 13010163 MAUREEN S OWNER'S NAME: ANTAL BRUCE G AND MAUREEN S 21744 REGNART CT DATE ISSUED:01/31/2013 OWNER'S PHONE: 4082533494 CUPERTINO,CA 95014-4834 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIALE] License Class Lie.1t KITCHEN REMODEL 225 SQ FT,M.BEDROOM 285 SQ FT, REMOVE AND REPLACE 18 WINDOWS AND 2 DOORS, Contractor Date REPLACE I hereby affirm that I am licensed under the provisions of Chapter 9 27 LIGHTS (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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$80000 1 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 APN Number:35624033.00 Occupancy Type: permit is issued. 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 WITHIN 180 DAYS 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 DAS OM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, Y ` 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: its`- Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature 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 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, Business&Professions Code) I,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(x)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 I / permit is issued. Owner or authorized agendo 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 indemnify and.keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. �/���l�( J/y Signatuk t'rVVw` _,W t tDate 1 3l CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION t V 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 U (408)777-3228• FAX(408)777-3333• building(a cupertino.org 1� CUPERTI.NO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS �?�-q4l h r, APN# OJIERN41t PHON)�f�,6S 25 39 E-MAIL GG ST ET ADDRESS cq. f Jq / CITY, S ATE,ZIP FAX CONTACT NAM , ' ►��n� �J ^ PHONf E-MAILnIfv C<g^ _0qV f cL A STREET ADDRESS CITY,STATEZIP FAX iv tso-70 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING US PROPOSED USE CONSTR TYPE #STORIES U V of USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN S/��� OTHER ((�� REMODEL AREA REMODEL AA � REMODEL A PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: UDETACH ❑ATTACH #DWELLING UNITSIS A SECOND UNIT ❑YES SECOND STORY []YES BEING ADDED? ED NO ADDITION? ❑NO / PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIV D B TOTP �rsp[.LJ N: PLANNING ADPL# ❑NO PLANNIIJG APPROVAL LETTER EICHLER HOME? [:]NO `I`�.-�(�l By Iny signature below,I certify to each of the following: 1 am the property owner or authorize&age0oact on the property owner's behalf. I have read this application and the information I have provided is correct. 1 have read the Description of Work and v6fify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to ul c nsUu ion. au o r:�w s �`upertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent:G/ � ate: /.. J(_-"0(-3 SUPPLEMENTAL INFORMATION REQUIRED PLAN CK TYPE ROUTING SLIP _ New SFD Or Multifamily dwellings: Apply for demolition permit for OVER-THE-COUNTER BUIL Y WLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building- permit for new building. ❑ EXPRESS PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doe revised 06/21/11 SARATOGA BUILDERS 1610 DELL AVE. STEN CAMPBELL, CA 95008 408-378-7002 JOB INFORMATION: NIR. & MRS. ANTAL 21744 REGNART CT. CUPERTINO, CA 95014 PERMIT NO. 13010163 SUB CONTRACTORS: SARATOGA BUILDERS 22518 A & J CALIFORNIA BUILDERS PYRAMID PLUMBING 29636 G 10 STON E/TONY VASSALLO PELLE HEATING & A/C 27593 CENTRAL CALIFORNIA INSULATION 557 T.D. ELECTRIC 28084 CALIFORNIA WINDOW & F/P 35145 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE- CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228- FAX (408)777-3333• buildino(aDcuDertino.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,. APN BP# OWNER NAME OWNE ADDRESS L COACt DESCRIPTION OF WORK; 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. 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. 4*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. 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. /q4. I understand Contractors are required by law to be licensed and bonded in California and to list their license nurhbers on permits and contracts. 4--5. 1 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. — - I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to.abide by these laws may subject me to serious financial risk. AW-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. �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. Oia nerBuilderForna 2010.doc revised 04/14/10 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal evenue 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 vnvw.cslb.ca.gov for more information about licensed contractors. W _10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. '40-11. 1 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. 4—K-1 2. 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. 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 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 requi d to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: 1J, Date: _ 3 a --------------------------------------------------------------------------------------------------------------------------------------------- (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 fora 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: 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: Oia:nei-BuilderForrn 2010.doc revisedO4114110