B-2017-0501CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0501
18660 PRING CT CUPERTINO, CA 95014-3822 (375 25 040) HOME BUILDERS &
DEVELOPMENT INC
CUPERTINO, CA 95015
OWNER'S NAME: PRING VENTURE LLC
DATE ISSUED: 08/03/2017
OWNER'S PHONE: I I PHONE NO: (408) 861-0928 I
LICENSED CONTRACTOR'S DECLARATION
License Class B Lic. #1025_0_1
Contractor HOME BUILDERS & DEVELOPMENT INC Date 04/30!2019
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
t. I have and will maintain,a certificate of consent to self -insure for Worker's
Compensation, as provided foi by Section 3700 of the Labor Code, for the
erfoimance of the work for which this permit is issued.
have and will maintainWorker'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.
APPLICANT CERTIFICATION
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 lhe�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- andwill comply with all non -point
source regulations per the Cupe.tino Municipal Code, Section 9.18.
Mg , ure Date 8/3/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I, as owner of the property, or, my employees with wages as their sole
compensation, will do the woik and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
z. I, as owner of the property, air exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for, which this
permit is issued. '
3. 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 Compensationl 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 forthwith•comply with such provisions or this permit shall
be deemed revoked.
APPLICANT CERTIFICATION ,
I certify that I have read this application and state that the above information is
correct. I agree to complywith 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 8/3/2017
BUILDING PERMIT INFO:
X BLDG —ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
CONSTRUCT (N) TWO STORY SFD (3756 S.F.); ATTACHED GARAGE
(430 S.F.); PORCH (178 S.F.)
Sq. Ft Floor Area: 3756 1 Valuation: $700000.00
"N Number: Occupancy Type:
375 25 040 R-3 (Custom)
PERMIT EXPIRES IF WORK IS NOT STARTED,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.`
Issued by: Jasmine Archbold
- RF ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 8/3/2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirementsunder Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain, compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I'store or handle hazardous
material. Additionally, should I 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.
,O
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0501
18660 PRING CT CUPERTINO, CA 95014-3822,(375 25 040) HOME BUILDERS &
DEVELOPMENT INC
CUPERTINO, CA 95015
OWNER'S NAME: PRING VENTURE LLC DATE ISSUED: 08/03/2017
OWNER'S PHONE: PHONE NO: (408) 861-0928
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO.
License Class B Lic. #1025631
Contractor HOME BUILDERS & DEVELOPMENT INC Date 04/30/2019 X BLDG — ELECT — PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH X RESIDENTIAL — COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect. JOB DESCRIPTION;
CONSTRUCT (N) TWO STORY SFD (3756 S.F.); ATTACHED GARAGE
I hereby affirm under penalty of perjury one of the following two declarations: (430 S.F.); PORCH (178 S.F.)
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Sq. Ft Floor Area: 3756 Valuation: $700000.00
APPLICANT CERTIFICATION
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 375 Number: Occupancy Type: '
and state laws relating to building construction, and hereby authorize 375 2S 040 R-3 (Custom}
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non-point
source regulations per the C, prtino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature bate 10-16-2018 Issued by: Jasmine Archbold
Date: 08/03/2017
OWNER-BUILDER
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for inspection.
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code). Date: 10-16-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3, 1 certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to becomesubject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety
Labor Code, I must forthwith comply with such provisions or this permit shall �--
be deemed revolted. Owner or authorized agent:
APPLICANT CERTIFICATION Date: 10-16-2018
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.)
• to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code, Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 10-16-2018 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0501
18660 PRING CT CUPERTINO,CA 95014-3822(375 25 040) HOME BUILDERS&
DEVELOPMENTINC
CUPERTINO,CA 95015
OWNER'S NAME:PRING VENTURE LLC DATE ISSUED:08/03/2017
OWNER'S PHONE: PHONE NO:(408)861-0928
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.81025631
Contractor HOME BUILDERS&DEVELOPMENT INC Data 04/30/2019 X BLDG_ELECT-PLUMB
1 hereby nflB•m that 1 nm Ilcensed carder the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
CONSTRUCT(N)TWO STORY SFD(3756 ST.);ATTACHED GARAGE
I hereby affirm under penalty of perha y one of the following two declarations: (430 S.F.);PORCH(178 S.F.)
i. 1 have and will maintain a certificate of consent to self-insure for Workers REV H I INSTALL A SAUNA IN MASTER BATHROOM-ISSUED 04-23-
Compensation,as provided for by Section 3700 of the Labor Code,for the 2018
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the won k for which this
permit is issued. Sq.Ft Floor Area;3756 Valuation:$700000,00
APPLICANT CERTIFICATION
I certify that I have read thtale that the above
is application and s
information is correct.I agree to comply with all city and county ordinances APN Number: Occepancy Type:
and state laws relating to building construction,and hereby authorize 375 25 040 R-3(Custom)
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 PERMIT EXPIRES IF WORI{IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 04-23-2018 Issued by:Jasmine Archbold
Date:08/03/2017
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
m. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offrcd for inspection
sale(Sec.7044,Business&Professions Code)
i. 1,as owner of the property,am exclusively emmacting with licensed Signature of Applicnnt:
contractors to construct the project(Sce.7044,Business&Professions Code), Date:04-23-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 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 ofdne work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous matertots requirements under Chapter 6.95 of Bre
Section 3700 of the Labor Cade,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534:1 will
permit is issued maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 use equipment ter devices which emit hazardous
centaminnnts as defined by the Bay Area Air Quality Management District I
Worlon's Compensation laws of Cali£arnia,If,after making this certificate of will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
exemption,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534,
Labor Code,I must forthwith comply with such provisions or this permit shall
be decnned revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:04-23-2018
1 certify that I have read this application and state that the above information is C1INSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there Is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for Inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lenders Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 04-23-2018 Licensed
Professional
NO FEE FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
24071660
Regina A l oomendras
Santa Clara County - Clerk -Recorder
11/29/2018 10:41 AM
Titles: 1 Pages: 3
Fees:10.00
0.00
Taxes: 0
Total:
111 WRAMPINNIIA, 5 f 14 ORM 11 IAI 911AI® 11111
NOVICE OF CITY REQUIREMENT TO MAINTAIN TREES
4
91
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ilk
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California
County of fit- Lkel-4- }
On IQ UV n , '2 �' before me, .J LL-�� lG- aAl �
(Here insert narrL1 and title of the officer)
personally appeared (4-0-
1� ,
who proved to me on the basis of -satisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and.acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, execrated the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.
WITNESS my hand and official seal ®S Pub>lue - CaliforniaMr
0a9
7-7
Notary P b 'c Signature (Notary Public Seal)
F/kIC�]tllliglt I!1; L U i� T I i�� r�� . , Iiia i�O1F�E! i►, rf
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
I I k.66
(Title or description of attachedddcument continued)
Number of Pages —I-- Document Date I d
CAPACITY CLAIMED BY THE SIGNER
Individual (s)
Corporate Officer
(Title)
El Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
2015 Version www.NotaryClasses.com 800-873-9865
IM,
INSTRUCTIONS FOR COMPLETING THIS FORM
NThis form complies with current California statutes regarding notary wording and,
if needed, should be completed and attached to the document. Acknowledgments
from other states may be completed for documents being sent to that state so long
,� as the wording does not require the California nota:y to violate California notary
law.
® State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
o Date of notarization must be the date that the signer(s) personally appeared which
must also bethe same date the acknowledgment is completed.
o The notary public must print his or her name as it Appears within his or her
commission followed by a comma and then your title (notary public).
m Print the name(s) of document signer(s) who personally appear at the time of
notarization:
o Indicate the correct singular or plural forms by crossing; off incorrect forms (i.e.
he/she/they— is /are ) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording:
® The notary, seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re -seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
a Signature of the notary public must match the signature on file with the office of
the county clerk.
Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
Indicate title or type of attached document, number of pages and date.
Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
• Securely attach this document to the signed document with a staple.
CALRFO ROA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this' certificate verifies only the identity of the individual who signed the document
to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of ,36,401
On MC)wm6ei 2� 159 before me, Luo J , T�,L1%,__ >
Date / Here Insert Name an Title of the Officer
l6
personally appeared ��'1�$ Le-y—
Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the ers O whose nam (s)&/are subscribed
to the within ins rnent and acknovvle e,d to -me that e he/they executed the same in 0/her/their
authorize capacit es), and t t by�erJtheir sig�n_at�ur� s) on the instrument the ers (s), or the .entity
upon behalf o vvhich the erso s acted executed the instrument.
p (� )
�s� , o� ;�� LAUREN` SAPUDAR
Notary Public r California Z
z ° Santa Clara County
z Y Commission'#2247155
"°°""� My Comm. Expir,s Jun 22, 2022
Place Notary Seal and/or Stamp Above
I certify under PENALTY OF PERJURY under the
laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature
Signature of Notary Public
OPTIONAL
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document:
� hjF 2�j�iv�-r.�, l� "N dy��" n T
Document Date: A Number of Pages:
Signer(s) Other Than Named Above: C_`l _X✓c�i��. 46veC40,
Capacity(les); Claimed by Signer(s)
Signer's Name:
❑ Corporate Officer - Title(s):
❑ Partner ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator
❑ Other:
Signer is Representing:
02017 National Notary Association
Signer's Name:
❑ Corporate Officer - Titfe(s):
❑ Partner - ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator
❑ Other:
Signer is Representing:
10) FEE FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded MaH To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
Regina A l comendras
Sana Clara County - Clerk -Recorder
11/29/2018 20:41 AM
Titles: I Pages: 3
Fees: 0.00
Taxes: 0
Total: 10.00
iii Wor'll KINN119 VA M1 RAN VAR 011, ®iii 1
--- - ------
NOTICE OF CITE REQUIREMENT TO MAINTAIN A PROTECTED LANDS CAP
The undersigned, being the owner(g) of the property shown in the Santa Clara County Assessor's Roll and identified as
A.P.N. 375-25-040 and addressed as 18660 Pring Court, hereby agree(s) that the approved landscape shall be maintained
and consistent to the approved plan in conjunction with Building Permit no. B-2017-0501, and shall be in conformance with
the City's Landscape Ordinance. The applicant may consult the City of Cupertino's Planning Department prior to any
modifications to the landscape; however, any proposed tree removals shall require approval by the Cit'°of Cupertino.
Changes to the plan may be made under the following conditions:
1. Plants that have water usage requirements consistent with the City's Landscape Ordinance as determined by the
Water Use Classifications of Landscape Species manual; or
2. Plants that are low-water using, native to California and appropriate for use in the area by the' Santa Clara Valley
Water District, Santa Clara Valley Chapter of the California Native Plant Society, the Master Growers Santa Clara
County, or a certified Landscape Architect or ISA certified Arborist; or
3. Preparation of new landscape and irrigation plans in conformance with Chapter 14.15 (Landscape Ordinance)
This declaration is binding on successors and assigns of the owner(s).
PROPERTY OWNER(S):
Owner's Signature
Print Owner's Name
Date
CITE' AUTHORIZATION:
r
Erika Poveda, Assistant Planner
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California
County of )
On N N , , ?,big before me, � u_w A �L, N A www QV&L,
(Here insert nanfe and title of the ofFcer)U
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and:that by
his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.
WITNESS my hand and official seal. � .®s�e�
�i;t1�:66i�a•ffi
Notary PubSignature (Notary Public Seal)
INSTRUCTIONS FOR COMPLETING THIS FORM
ADDITIONAL ®PTB®NAIL ONS®MATI®N This form complies with 'current California statutes regarding notary wording and,
DES)�RIPTION OF THE ATT CHED DOCUMENT
,
ifneeded, should be completed and attached to the document. Acknowledgments
from other states may be completed for documents being sent to that state so Jong
the does the California notary to violate California notary
p
as wording not require
C r
Qgiv.
(Title or description of attached ocument)
a State and County information must be the State and County where the document'
(�
signer(s) personally appeared before the notary public for acknowledgment.
(Title or description of attached document continued)
Date of notarization must be the date that the signer(s) personally appearedwhich
must also be the same date the acknowledgment is completed.
6-'
e The notary public must print his or her name as it appears within his or her
Number of Pages Document Date
commission followed by a comma and then your title (notary public).
e Print the name(s) of document signer(s) who personally appear` at the time of
notarization
CAPACITY CLAIMED BY THE
1.1
Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
IGNER
o Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/& ;- is /are ) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
e The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re=seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
e Signature of the notary public must match the signature. on file with the office of
the countyclerk.
Additional information is not required but could help to °ensure this
acknowledgment is not misused or attached to a different document.
Indicate title or type of attached document, number of pages and date.
Indicate the capacity claimed by the signer. If the claimed capacity is a''
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
2015 Version www.NotaryCIasses. corn 800-873-9865 m Securely attach this document to the signed document with.a staple.
C L11FOO Rini ALL-PURPOSE ACKNOWLEDGMENT I`111 CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document
to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of _ Y01A!_ C_ I G,
On %M_M Ger- 1 before me, CLCA VtA
Date Here Insert Name and Title of the Officer
personally appeared HCAe. �.� ke_
Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose(nam (s) s/ re subscribed
to the within instrument and acknowledged to me that she/they executed the same in /her/their
authorize �apacit ies), and t at by/her/their signatu (s) on the instrument th erso s), or the entity
upon behaffhich theerso s) acted, execute -Me instrument.
ryp� LAUREN SAPUDAR
(dotary Public • catifornia z
Santa tiara County a
Commission # 22479 55-
C44Pn0.7P .fly Comm. Expires Jun 22, 2022
Place Notary Seal and/or Stamp Above
I certify under PENALTY OF PERJURY under the
laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature
Signature of Notary Public
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: o UAAJA
Document Date:- Number of Pages:
Signer(s) Other Than Named Above: CA i>,0A
Capacity(les) Claimed by Signer(s)
Signer's Name:
❑ Corporate Officer - Title(s):
❑ Partner - ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator
❑ Other:
Signer is Representing:
02017 National Notary Association
Signer's Name:
❑ Corporate Officer - Title(s):
❑ Partner ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator
❑ Other:
Signer is Representing: