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11050049 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22650 SILVER OAK LN CONTRACTOR:PRIYA SUMAL PERMIT NO: 11050049 OWNER'S NAME: PRIYA SUMAL 22650 SILVER OAK LN DATE ISSUED:05/09/2011 '"WNER'S PHONE: 4089107675 CUPERTINO, CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION IW- W BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# f F_ MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION: REPLACE 9 WINDOWS AND I SLIDING DOOR LIKE FOR I hereby affirm that I am licensed under the provisions of Chapter 9 LIKE (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:$6675 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 APN Number:34249002.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT E S IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN B YS 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 M 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:,. �r 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 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) 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(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: 0 Dater 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. ,ing 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. Signature - Dated CONSTRUCTION PERMIT APPLICATION [a COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 •FAX(408)777-3333•building )cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# V L PROJECT ADDRESS APN# OWNER NAME PHONE E-MAIL hri A SoMakAo�� �lG- 7� 7S nkC "v_ir �i 0`1 ullr.�o.GONt STREET ADDRESS CITY, STATE,ZIP FAX 1 LJ\ i� 0 A K uov cu-�fr f�,-c i N(., C A r1 L �t CONTACT NAME PHONA 7 E-MAIL yf,l A SvYLl1�L/ `-rCCj - l(0 l (c',7� 1 4 SorAGtr v ul J-00• C-vy- STREET ADDRESS CITY,STATE, ZIP FAX 22- SD Q," ©cO2 Ute► C u e ir Vi A 0 1 c� ❑OWNER OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# 7 4 0 COMPANY NAME E-MAIL FAX Y�OSQ1,O_ .w\I� O nl LO C� Ck IIS c �r v .cJco, ars STREET ADDRESS CITY,STATE,ZIP PHONE 2-2-OD L_ ;�-A }fie `>F, L:'r�i `ici,\_kk CIS-(a C,4 q.5-6 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK /'e_ A (,Lllndows C (17 a4-1 boo 16)"3� `1tu�v� ?��g t st�d�>n C; = coA-M ?ISTDN USE PROP95ER ISE/ COT TYPE #sT R 1 EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA fi BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKMORCH AREA GARAGE AREA:❑ DETACH ❑ ATTACH rf N DWELLING UNUS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? ❑NO r s �=' �:�:.�.`,� �u• ;V.,, 'K;, �:a� .,s, 0"M p v PRE-APPLICATION ❑ YES IF YES,PROVIDE COPY OF PLANNER'S NAME: `a GIN ra�.a PLANNING APPL M [3 NO PLANNING APPROVAL LETTER By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's beha . I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I orize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: l SUPPLEMENT A L RMATION REQUIRED New SFD or Multifamily dwellings: Apply for demolition permit for a � cQ��� � w � existing building(s). Demolition permit is required prior to issuance of building §� d permit for new building. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure d sTnrlLht dl ©x pTIB IGWbiu form if any Hazardous Materials are being used as part of this project. Q URGE e�fr vSL _Copy of Planning Approval Letter or Meeting with Planning prior to I� 1VfAJGIR ��lIIIR77i"SEV{r�R,.13iSTRi� submittal of Building Permit application. BldgApp_201 1.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION JDDRESS: 22650 Silver Oak Ln. DATE: 05/09/2011 REVIEWED BY: gs PN: BP#: "VALUATION: $6,675 "PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Du lex PENTAMATION 1 GENRES USE: p PERMIT TYPE: WORK SCOPE NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept-for addh 7 info. FEE ITEMS (Fee Resolution 09-051 E;ff 7, 1110) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Window/Sliding Glass Door Suppl.PC Fee: E) Reg. 0 OT 0.0 1 hrs $0.00 $506.00 IWINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl.Insp.Fee-0 Reg. 0 OT 0.01 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes (F) No $0.00 0 Work Without Permit? 0 Yes E) No $0.00 E) PlanninfzFee: $0.00 Select a Non-Residential E) Building or Structure 0 A Strong Motion Fee: IBSEISMICR $0.67 Select an Administrative Item Bld�7 Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $1.671 $506.00 TOTAL FEE: $507.67 Revised: 04/29/2011 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN 34249002 . 00 DATE ISSUED. . . . . . . : 05/09/2011 RECEIPT # . . . . . . . . . BS000013400 REFERENCE ID # . . . : 11050049 SITE ADDRESS . . . . . : 22650 SILVER OAK LN SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PRIYA SUMAL ADDRESS . . . . . . . . . . : 22650 SILVER OAK LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PRIYA SUMAL CONTRACTOR LIC # *OWNER* COMPANY . . . . . . . . . . : PRIYA SUMAL ADDRESS 22650 SILVER OAK LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 6, 675 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 6 , 675 . 00 0 . 67 0 . 00 0 . 67 0 . 00 1WINREP EACH 8 10 . 00 506 . 00 0 . 00 506 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 507 . 67 0 . 00 507 . 67 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 507 . 67 visa --------------- TOTAL RECEIPT 507 . 67 COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION-CUPERTWO Priya Sumal APPROV�D 22650 Silver 'atTons MUST be kept H�etL tconstructlon. It is unlawful to mak c~ar c as ar alterations �n same,or to devl therefrom, without approval from the Building 6068 x PDR no stn no!ng of this plan nd specifications SHA CT sliding door) temper t, he�lri to rrn't a e an a. u;oval of the vlo vtc��Stry cavi C �� �� ( � �Y P"�r�� r rc. 32"x44" RC O4,;s� t;y Orainan�gtate Master bedroom DATE VIM" PEr=tMIT ho. Hall temper 2nd bedroom ^ 7 bath 321Ix44" 3211x44" -tvr4 (temper) i nuns,-rue 44" x56" bath (temper) 4411x56 44"x56" v"C c- Kitchen/Dining living room 4311x32" 68"x56" (temper) ne�SKuctviaQ �Zc,,.SlrveEJ�e� WINDOW REPLACEMENT REQUIREMENTS COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL LM 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTIMq (408)777-3228•FAX(408)777-3333•buildingCca7cupertino.org PURPOSE The purpose of this guideline is to clarify the minimum building code requirements when repairing, replacing or adding windows.in a residential building. Structural plans and calculations may be required if window/door openings are added to an existing lateral resisting element(shearwall). PLAN REQUIREMENTS 1. Provide a completed building permit application. 2. Provide three sets on minimum 8-1/2"x 11" sheets of completely dimensioned floor plans showing the size,type and/or location of all new or replacement/repaired windows. Floor plan shall specify the use of all existing rooms. 3. Owner-Builder Disclosure Form (for property owners applying for their own building permit) 4. Provide structural plans and calculations if window/door opening is(are)being added to an existing shearwall and the overall design does not meet the conventional construction requirements of the California Building Code. GENERAL INFORMATION—EMERGENCY ESCAPE AND RESCUE OPENINGS • Per the 2010 CRC Section R310 and 2010 CBC Section 1029, provisions shall be made for emergency escape and rescue in Group R occupancies. These requirements also applies to replacement windows per 2010 CBC Section 3407. • Every sleeping room shall have at least one exterior emergency escape and rescue opening or exterior door approved for egress or rescue. • All emergency escape and rescue openings from sleeping rooms shall have a net clear opening of 5.7 square feet, except that the minimum net clear opening for emergency escape and rescue grade- floor openings shall be 5 square feet. • The minimum net clear opening height shall be 24 inches. The minimum net clear opening width shall be 20 inches. • Emergency escape and rescue openings shall have the bottom of the clear opening not greater than 44 inches measured from the floor. • Bars, grills, grates or any similar devices are permitted to be placed over emergency escape and rescue openings provided the minimum net clear opening size complies with the opening requirements of the egress window and such device shall be releasable or removable from the inside without the use of a key,tool, special knowledge or effort or force greater than that which is required for normal operation of the escape and rescue opening. • Bars, grills, grates or any similar devices shall be equipped with an approved exterior release device for use by the fire department. WindowReplacePolicy.doc revised 2/25/11 Request for Architectural Change Silver Oaks West Homeowners Association 1935 Dry Creek Rd. Campbell,CA 95008 Phone: 408-559-1977 Fax: 408-559-1970 Repair/Replacement to be performed(attach a picture or drawing if necessary): All 9 windows in unit 22650 are to be replaced with Milgard Tuscany windows. The sliding door in unit is to be replaced as well. No structural changes are being made — this is a retrofit project. Work is estimated to start at the end of May (pending window delivery). All work should be completed by June. Will a Contractor be used?_�_yes no If yes, (- L Contractor's Name License Phone If yes, but Contractor unknown at this time, please initial the following: I agree to engage a California licensed contractor which will: provide its own liability and worker's compensation insurance; observe all applicable laws, regulations, and building codes; and employ industry accepted building and remodeling practices. I will assume full responsibility for paying the contractor(s). 1�:_..?J (initials) Work to begin by: —05_/_D!201 1— Work to be completed by: _„_06 / 17 12011 Is this architectural change covered by an existing HOA specification? ,_4_yes no tr If yes, I have read the HOA specification and will ensure that the work complies with the specification. 1-�� (initials) Agreement I will not bind the Association to any contract,nor will the Association be a party to any contract related to the repairs. I will assume full financial responsibility for reimbursing the Association,other owners,or injured parties for any damages which may arise in conjunction with the building repairs from my actions or those of the contractor(s). I will ensure that all work is completed within a reasonable time from its onset and that the final appearance of my home will be consistent with the architectural detail and color characteristics that existed prior to repair/replacement. I understand that,in granting approval to make necessary repairs,the Association does not accept liability for the outcome or effectiveness of these actions,and that the Association assumes no responsibility for implementing these or similar modifications in any other home. By undertaking the abbe-mentioned repair/replacement,I agree to be bound by these terns. AL (Owner's signa re)`---- (Phone numbers} (Address) (Date) Approved by Manager or Board of Directors Date Updated 0711411008. OWNER-BUILDER NOTICE COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX(408)777-3333- buildingecugertino.org Effective January, 1, 2009, Assembly Bill 2335 amends California Health and Safety Code, Section 19825, regarding disclosures and verifications required for all applicants seeking Owner- Builder construction permits. These new application requirements provide an enhanced level of consumer awareness and protection for property owners accepting the risks associated with Owner-Builder construction permits. "The Legislature hereby finds and declares that there is an urgent and statewide public interest in assuring that building contractors comply with the Contractors License Law...and provisions of law relating to Workers' Compensation Insurance for building construction, that property owners are informed about, and protected from, fraudulent representations, liability for worker's injuries, liability for material and labor costs unpaid by contractors, licensing requirements, and employer's tax liabilities when improving their property as owner-builders" 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: "os,00 ! gv.­i t with Low 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: and Significant Financial Risk Owner-as-Employer is a type of Owner-Builder where you pay any 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. Benefit/Risk: with Significant Financial Risk 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. OwnerBuilder 2010.doc revised 06/08/10 OWNER-BUILDER DISCLOSURE FORM La COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX(408) 777-3333•buildina(cr)cupertino ora 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 SU S1 10C r A k T�� BP# OWNER NAME OWNER ADDRESS f S l k - Al l Vto r1 �1SZ) DESCRIPTION OF WORK: r Ci 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.) a_1- I understand a frequent practice of unlicensed persons is to have the property Builder" building permit that erroneously implies that the property owner is providing his or her oobtain dwn 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. (6_2. 1 understand building permits are not required to be signed b property the construction and are not hiring a licensed Contractor to assume this responsibilityowners unless they are responsible for 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I undrstandprotect myself from potential financial risk by hiring a licensed Contractor and having the permit fil den his orhher may name instead of my own. � 4. I understand Contractors are required by law to be licensed and bonded in California an numbers on permits and contracts. d to list their license -L(--> 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, total value of my construction is at least five hundred dollars ($500), including labor and materials, I may beand the considered an "employer' under state and federal law. X `yL6. I understand if I am considered an "employer" under state and federal law, I must register federal government, withhold payroll taxes, g ster with the state and unemployment compensation or each "employee." a�oeunderstand my failucompensation re a ttolab de bty y the and contribute j me to serious financial risk. y se laws may subject 7. 1 understand under California Contractors' State License Law, an Owner-Build er who residential structures cannot legally build them with the intent to offer them for sale, unless allbuilds worrk islperformed b licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of y is performed under contract with a licensed general building Contractor. the work R� 8. 1 understand as an Owner-Builder if I sell the property for which thispermit is issued, any financial or personal injuries sustained by any subsequent owner(s) that result from any latent cb nstructionheld for defects in the workmanship or materials. OwnerBuilderForm_2010.doc revised 04/14/10 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. _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. X, 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. e( 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. 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 m required to be presented when the permit is issued to verifythe property owner's si nat e., Property Owner's Signature: V. 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. 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: OwnerBuildeYForm_2010.doc revised 04/14/10