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12080029-EXPIREDI CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10931 MAXINE DR I COLLACTOR: WONG ALLEN AND I PERMIT NO: 12080029 OWNER'S NAME: WONG ALLEN AND LILLIAN I P O BOAC 700005 1 DATE. ISSUED: 08/17/2012 1 OWNER'S PHONE: 4082098902 SAN JOSE, CA 95014 1 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG (_ ELECT r PLUMB License Class Lic. k Contractor I hereby affirm that 1 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. 1 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 provideor APPLICANT CERTIFICATION 1 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. costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature, Date ❑ OWNER -BUILDER DECLARATION ¢ 1 hereby affirm that 1 am exempt from the Contractor's license Law f�-one of the following two reasons: 1, as owner of the property, or my employees with wages as their sple compensation, will do the work, and the structure is not intended or offered for sale (S 7044. Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed co tors to construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 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 W6rker'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. 1 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CER'T'IFICATION 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. _ DateZ11?_ MECH F RESIDENTIAL � COMMERCIAL JOB DESCRIPTION: ADDITION OF DEMISING WALL AND ONE (1) DOOR (100 SQFT) Valuation: $2000 APN Number: 32602052.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: �� 7�}%G Date: RE: ROOFS: All mofs .ha( inspected prior to any roofing material being installed. If a roof is installQd witfiout first obtaining an inspection, 1 agree to remove all new materials for �{'S ictibil. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER IIAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth & Safety Code, Section 25532(a) should 1 store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner at thorized agent: (jg� / 7—' n Date: U ( L CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Add ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO PROJECT DATA, - COMMERCIAL COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • building(@cupertino.orq PROJECT ADDRESS , APN # MA X ItLe ail. OWNER NAME PHONE \ E-MAIL p� a 1— STREET ADDRESS , CITY TATE, ZIP FAX 40231 Aa)(l&p 9101 Q CONTACT AME PHO E-MAIL UnCLdd STREET DRESS CITY, STATE, ZIP FAX y17' El OWNER ElOWNER-BUILDER❑ OWNER AGENT ❑CONTRACTOR LJCONTRACTOR AGENT ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT TENANT CONTACT ME PHONE E-MAIL A40 Z BUSINESS NAME FAX BUILDING r`D TF'TIQ-NTT .SPACE T)D ""'nNTc DESCRIPTION OF WORK r EXISTING USE(S): PROPOSED USE(S): OCCUPANCY(S): �, -� OCCUPANT TYPE OF 1 / , n LOAD: CONSTRUCTION V AREA OF / FLOOR(S) HAZARDOUS Y N REMODEL SPACE: OF REMODEL SPACE: MATERIALS? FIRE Y 1J WUI Y N FLOOD Y N SIESMIC Y N SPRINKLERS: t AREA : AREA: AREA: NUMBER OF CHILDREN < 2 YRS OLD: NUMBER OF STUDENTS — 2 YRS OLD UP TO 12TH GRADE: LEARNING CENTERS AND 24 HOURS CARE? Y NUMBER OF ADULT CLIENTS: EDUCATIONAL OPERATIONS: NUMBER OF EMPLOYEES: TOTAL OCCUPANTS: Governing Codes: 2010 California Building Code (based on the 2009 International Building Code) 2010 California Residential Code (based on the 2009 International Residential Code) 2010 California Plumbing Code (based on the 2009 Uniform Plumbing Code) 2010 California Mechanical Code (based on the 2009 Uniform Mechanical Code) 2010 California Electrical Code (based on the 2009 International Electrical Code) 2010 California Energy Code 2010 California Green Building Standards Code Cupertino Municipal Code ProjectData-Commercial.doc revised 12/01/11 �- f,4-6 2 c� � CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 G U P E RT I N O (408) 777-3228 • FAX (408) 777-3333 • bulldiinng0cupertino.ora NEW CONSTRUCTION � ADDITTON � ALTERATION / TT I I RFViSiON / DF.FF.RRF.D ORIGINAL PFRMTT # U � 2-9 PROJECT ADDRESS / ncy APN # OWNEME / PHO E E-MAIL - _J_ &1)2 _100,p� d STREET ADDRESSCI Wax, 141 rly STATE, ZIP cl -t J FAX CONT NA E EMAIL G L._ STREET DRESS_ CI STATE, -4 - -- FAX ❑ 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 NA J�gX LICENS NUMBE BUS. LIC # COMPANY N E-MAIL FAX C STREE ADDRfA CI STATE, ZIP PHONE r DESCRIPTION OF WORK \ i EXISTING USE PROPOSED USE CONSTR. TYPE # STOMY r" USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLMR DEMO TOTAL AREAr4- AREA AREA �. NET AREA BATHROO KITCHEN REMODELLA REMODEL AREA REMODELAREA PORCH AREA DECK AREA TOTAL DECK/PORCH ARE GARAGE AREA: DETACH B ATTACH I # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ONO ADDITION? ONO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO - 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 behalf. 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 authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: yyi Date: SUPPLEMENTAL INFORMATION REQUIRED PL HECK TYPE ROUTING SLIP R-THECOUNTER ❑ _ New SFD or Multifamily dwellings: Apply for demolition permit for/EXPI existing building(s). Demolition permit is required prior to issuance of building BUILDING PLAN REVIEW permit for new building. ESS ❑ 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 B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION IvaADDRESS: 10931 maxine ave. FLR AREA s.f. DATE: 08/06/2012 REVIEWED BY: larry s BP FEES l APN: �Z�p Q�, Q� BP#: II-B,III-B,IV,V-B *VALUATION: 1$2,000 'PERMIT TYPE: Building Permit PLAN CHECKTYPE: Tenant Improvement PRIMARY USE: Commercial Building IETIINSP i;lcf Inv), l"'c, PENTAMATION PERMIT TYPE: 1 E TI WORK addition of demising wall and 1 door SCOPE $392.00 Suppl. Insp. Fee -0 Reg. ® OT OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEED BP FEES BP FEE ID E (Tenant Improvements) II-B,III-B,IV,V-B 100 $3,066.00 IETI LNCK $392.00 IETIINSP i;lcf Inv), l"'c, $0.00 Permit Fee: $392.00 Suppl. Insp. Fee -0 Reg. ® OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 100 $0.00 $392.00 MECIII, HOURLY O Yes 0 No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY Q Yes Q No loch. Plan Chet{ Plumb. Plan C; r. Plan Che, . Vfech. Perm Plumb. P Elec. Permit Fee: cher Afech. hisp. Other Plumb Insp. Other Elec. Insp. Li f� ( h hr"p, /', r $0.00 i;lcf Inv), l"'c, NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc). These lees are based on the preliminary information available and are only an estimate. Contact the Dept for addh 7 into. FEE ITEMS (Fee Resolution 11-053 E,ff 7./1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? O Yes O No $0.00 8 hours Plan Check, Hourly $1,064.00 ISTPLNCK i Suppl. PC Fee: Q Reg. Q OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $392.00 Suppl. Insp. Fee -0 Reg. ® OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction KIX. l dtninistrative .Fee: O 0 Work Without Permit? O Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 0 i arca I�ocrurtcrratulinrl Fees: Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $393.501$1,064.00 TOTAL FEE: $1,457.50 Revised: 07/01/2012 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: / ,3J ,¢ �/ PERMIT # -;Oz O� OWNER'S NAME: 471721n-11D.O PHONE # GENERAL CONTRACTOR: GLGlN� yr 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 INSPECTIONS) 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 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 / Signature 17-12, Date CUPERTINO OWNER -BUILDER NOTICE COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - build6ci(cDcuoertino.ora 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 ac ting 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: Poscibke Benefit with Lo%N Financial Rick 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 tum to serious financial risk if you hire unlicensed contractors to perform any of the work. Benefit/Risk: Possible Benefit and Significant Financial Risk Owner -as -Employer is a type of Owner -Builder where you pay any 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 tum to serious financial risk if you fail to deduct payroll taxes or provide workers compensation insurance for each worker. Benefit/Risk: Poscible Benefit with Ci«nificant 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 Following are alarming examples of what has occurred with Owner -Builder permits: Example 1: Homeowner received insurance money to rebuild burned -down home. ■ Owner/Builder permit pulled to rebuild structure. • Unlicensed contractor built substandard structure — must be torn down and replaced. • Estimated financial injury is $225,000. • Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of the year. Example 2: Brother-in-law had active license but filed an exemption from Workers Comp. ■ Owner -Builder hires brother-in-law to install a new roof. ■ Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and remains in a coma to this day. ■ The Owner -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic system and suffers injury that results in permanent disability. ■ The Owner -Builder did not have a homeowner's insurance policy on the house against which to submit a claim. ■ The Owner -Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Did you know — unlicensed persons frequently have the property owner obtain an "Owner - Builder' building permit which erroneously implies that the property owner is providing his or her own labor and material personally? Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your property by an unlicensed contractor and his/her employees? Did you know — if you are considered an "employer" under state and federal law, you must register with the state and federal government, withhold payroll taxes, provide workers compensation and disability insurance and contribute to unemployment compensation for each "employee"? Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk? OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR YOUR CONSTRUCTION PERMIT OwnerBuilder 2010.doc revised 04/12/10 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildino(a1cuoertino.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: 85011 SITE ADDR SS t x o, �e fv t(41IOLWNER P APN BP# OWNER AME t , Ik V ADDRESS DESCRIPTION OF WORK: i0it-) MAI 0014A N141 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.) JLAA I 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. LW2. I 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. OL13. 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. 44 I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. J'A5. 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. ILIL"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 me 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 performed under contract with a licensed general building Contractor. Viy8. 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. OrnerBuilderForm 2010.doc revised 04/14/10 A9. I 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.csib.ca.gov for more information about licensed contractors. V&[10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I alp the party legally and financially responsible for proposed construction activity at the site address listed above. 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. 10112. 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 required to be presented when the permit is issued to verify the property owner's signature_ Property Owner's Signature: 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: 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