13020001CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21087 GRENOLA DR
CONTRACTOR: TZE SU
PERMIT NO: 13020001
OWNER'S NAME: TZE SU
21087 GRENOLA DR
DATE ISSUED: 05/23/2013
OWNER'S PHONE: 4083168708
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class Lie. #
NEW 2 STORY HOME (1ST FLR 2122SF, 2ND FLR 1253 SF
& 2 GARAGES TOTAL 730SF)
Contractor Date
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:
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
Sq. Ft Floor Area:
Valuation: $615750
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 work for which this
APN Number: 32628008.00
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 DAY 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 DAYS F ST 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
Iss 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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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.I2 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, Section 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date: 3 '
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, l
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
1 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
y3
Signature G Date
CUPERTINO
/NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(d)cupertino.org
❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS2 6./—,/ U r
APN #
b
OWNERNAME �/% �`"
PHONE
E-MAIL
STREET ADDRESS /
CITY, ESTATE, ZIP
FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS C&CLi Sr?
CITY, STATE, ZIP �
FAX
p
i
P
O
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT 11 CONTRACTOR 11 CONTRACTOR AGENT Id/ARCHITECT 11 ENGINEER 11DEVELOPER❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME /A �� C —� / Q�
J /H
LICENSE NUMBER �, _ , • a
�L 5
BUS. LIC #
COMPANY NAME w( E-MAIL
FAX
/
STREET ADDRESSJ G CITY, S TE, ZIP
PHON
DESCRIPTION OF WORK _22 o7ize_
A( FL- /eAr
�I'd FL ° /yl, Re. -J v . Al. Gv'/. G /L/. 514T! i #e.,[ inn 2 ,B Y/y- 3.
EXISTING USE
��. Ie - � '11
PROPOSED USE CONSTR.
S -,,t/
TYPE
�/ ?1
Y f�
# STORIES
USE TYPE OCC,
SQ.FT.
VALUATION ($)
EXIS G
NEW FLOOR
DFMO
TOTAL
AREA
AREA 0
AREA
NET AREA
7
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: TACH
4�. s.f
73 s.
i1_7
1 s F
�� . <.F ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY YES
BEING ADDED? NO
ADDITION? []NO
PRE -APPLICATION EJYES IF YES, PROVIDE COPY OF
IS THE BLDG AN YES
RE
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 auth zed agent t on the property owner's behalf. I hhave read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable Iocal
ordinances and state laws relating to building construction. I authoriz representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: '� Date:L
SUPPLEMENTAL INFCWMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER -THE COUNTER
UILDING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
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
TANDARD
PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑
'
LARGE
>13TRE DEPT
_ Copy Of Planning Approval Letter or Meeting with Planning prior t0
❑ MAJOR
SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 1. doc revised 06/21/11
CITY OF CUPERTINO
F -M-7- FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
21087 GRENOLA DR
DATE: 02/01/2013
REVIEWED BY: MELISSA
jWADDRESS:
APN: 326 28 008
BP#: C
*VALUATION: $615,750
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: New Construction
PRIMARY SFD or Duplex
USE:
2nd Unit? Yes No
PENTAMATION 1R3SFDW
PERMIT TYPE:
WORK
NEW 2 STORY HOME 1 ST FLR 2122SF 2ND FLR 1253 SF & 2 GARAGES TOTAL 730SF
SCOPE
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,111-B,Iv,v-B
4,105
$3,058.38
IR3PLNCK
$3,358.32
IR3INSP
$0.00
PME Plan Check:
$0.00
Permit Fee:
$3,358.32
Suppl. Insp. Fee -0 Reg. OT
1 0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
TOTALS:
4,105
$3,058.38
Construction Tax: IBCONSTAXR
$3,358.32
# new
units
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$3,058.38
Li
Suppl. PC Fee: 0 Reg. OT
0.0
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$3,058.38
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: 0 Reg. OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$3,358.32
Suppl. Insp. Fee -0 Reg. OT
1 0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXR
1
# new
units
29
.Idninisu'ative Fer:
0
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee: 1PLLONGR
$533.65
Select a Non -Residential
Building or Structure
,
II
i "
i(ii'C /.)UC'1!fi7 c'h71':,.i'.1.
Strong Motion Fee: IBSEISAfICR
$61.58
Select an Administrative Item
Bldg* Stds Commission Fee: IBCBSC
$25.00
'SUBTOTALS:
$7,666.22
$0.00
TOTAL FEE.
$7,666.22
Revised: 10/01/2012
N I
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: 2( 0 8 17 4�/Z&7l/Oc{ p/2 .
PERMIT # / T0 7 -00.D /
OWNER'S NAME: Vq
PHONE # C4 -d8 a5 i;: —
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS: I oro �V S- Ave
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
Owner /Contractif Signature
ate
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 /Contractif Signature
ate
Service Center
10555 Mary Ave
Cupertino, Ca 95014
Office: (408)777-3410
Fax: (408) 777-3399
CUPERTINO
CITY OF CUPERTINO STREET TREE PLANTING REQUEST
The following is a list of available street trees for replacement or new installation. PIease
fill out form and return it, either by mail, fax or in person, to the above address.
Some neighborhoods have theme Street Trees (only one tree type approved). Details on
themed Street Tree Neighborhoods and information on the below trees can be found on
the City's Website www.cul2ertino.org1trees
DATE
NAME
ADDRESS
PHONE#
Botanical Name Common Name
❑ ACER. RUBRUM. 'October Glory'
❑ ARBUTUS 'Marina'
❑ FRAXINUS AMERICANA
❑ FRAXINUS UHDEI
❑ GINTKGO BILOBA. `fairmont'
❑ KOELREUTERIA BIPINTNATA
❑ LAGERSTROEMIA X FAURIEI HYBRIDS. `Tuscarora'
❑ PISTACIA
❑ PLATANUS
❑ PYRUS CALLERYANA 'aristocrat'
❑ PYRUS CALLERYANA `chanticleer'
❑ QUERCUS AGRIFOLIA
❑ TRISTANIA. CONFERTA
Final tree selection must be approved by Trees and ROW Supervisor.
Red Maple
Strawberry Tree
Autumn Purple Ash
Shammel Ash
Maidenhair Tree
Chinese Flame Tree
Crepe Myrtle
Chinese Pistache
Sycamore
Flowering Pear
Chanticleer Pear
Coast Live Oak
Brush Box
CUPERTINO
November 1, 2012
OFFICE OF COMMUNITY DEVELOPMENT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 `
(408) 777-3308 - FAX (408) 777-3333 • plannin(cDcupertino.org A4
Sy -Cheng Tsai
Rong Chang USA, Corp.
2050 Concourse Drive. #50
San Jose, CA 95131
Re: Two -Story Permit, file no. R-2012-38
21087 Grenola Drive
Dear Sy -Cheng:
APf� 4,g
2013
Thank you for your application received on October 4, 2012 for a Two -Story Permit on the
property located at 21087 Grenola Drive. After reviewing the application, Planning Division
staff has determined that your application is complete in accordance with the Permit
Streamlining Act (California Government Code section 65920).
Planning staff will now proceed with the processing of your application. Please send me the 3D
perspective/rendering of the proposed home for approval. When approved, please post on
the notice board onsite along with the other required information. The City will send out
notices to the adjacent neighbors for a two-week comment period after this is verified. An
action letter detailing the decision and conditions of approval will be sent in the mail after the
public comment deadline. A two week appeal period will follow the Community Development
Director's decision.
If the application is approved, the following conditions of approval will apply, in addition to
the standard conditions:
1. Construction plan set revisions/clarifications and items needed prior to issuance of
building permits:
a. The applicant shall work with staff to incorporate pervious and/or semi -pervious
pavement on the new driveway.
b. The existing fence within the public right-of-way shall be removed.
c. Privacy trees and shrubs shall be noted on the planting plan to be planted at least 8 feet
and 6 feet high, respectively.
d. The space between the proposed privacy shrubs on along the east side shall be addressed
through at least one of the following measures:
21087 Grenola Drive
R-2012-38
• Raise second floor window sill above 5 feet from the finish floor.
• Plant privacy trees or shrubs to fill this space.
• Provide affected property owner's waiver agreeing to the space between plantings.
2. Front yard tree:
Per the R1 Ordinance, a new minimum 24 -inch box, 8' high front yard tree is required to be
planted in the front yard with the intent to eventually screen the massing of the second
story.
3. Landscape project submittal:
Prior to issuance of building permits, the applicant shall submit a full landscape project
submittal per sections 14.15.040 A, B, C, and D of the Landscaping Ordinance. The Water -
Efficient Design Checklist (Appendix A of Chapter 14.15), Landscape and Irrigation Design
Plans, and Water Budget Calculations shall be reviewed and approved to the satisfaction of
the Director of Community Development prior to issuance of building permits.
4. Landscape installation report:
Prior to final inspection, a landscape installation audit shall be conducted by a certified
landscape professional after the landscaping and irrigation system has been installed. The
findings of the assessment shall be consolidated into a landscape installation report.
The landscape installation report shall include, but is not limited to: inspection to confirm
that the landscaping and irrigation system are installed as specified in the landscape and
irrigation design plan, system tune-up, system test with distribution uniformity, reporting
overspray or run-off that causes overland flow, and preparation of an irrigation schedule.
The landscape installation report shall include the following statement: "The landscape and
irrigation system have been installed as specified in the landscape and irrigation design plan
and complies with the criteria of the ordinance and the permit."
5. Landscaping maintenance schedule:
Per the Landscape Ordinance (CMC, Chapter 14.15), a maintenance schedule shall be
established and submitted to the Director of Community Development or his/her designee,
either with the landscape application package, with the landscape installation report, or any
time before the landscape installation report is submitted.
a) Schedules should take into account water requirements for the plant establishment
period and water requirements for established landscapes.
b) Maintenance shall include, but not be limited to the following: routine inspection;
pressure testing, adjustment and repair of the irrigation system; aerating and de -
thatching turf areas; replenishing mulch; fertilizing; pruning; replanting of failed plants;
weeding; pest control; and removing obstructions to emission devices.
c) Failed plants shall be replaced with the same or functionally equivalent plants that may
be size -adjusted as appropriate for the stage of growth of the overall installation. Failing
21087 Grenola Drive
R-2012-38
plants shall either be replaced or be revived through appropriate adjustments in water,
nutrients, pest control or other factors as recommended by a landscaping professional.
6. Landscaping maintenance agreement:
Prior to final inspections and final occupancy, the owner(s) of the property shall enter into a
formal written landscape maintenance agreement with the City. The City shall record this
agreement, against the property or properties involved, with the County of Santa Clara
Recorder's Office and it shall be binding on all subsequent owners of land served by the
proposed landscape. The landscape maintenance agreement shall require that the installed
landscape not be modified and that maintenance activities not alter the level of water
efficiency of the landscape from its original design, unless approved by the City prior to the
commencement of the proposed modification or maintenance activity.
If you should have any questions, please contact me at (408) 777-7601 or by e-mail at
georges@cupertino. org.
Sincerely,
George Schroeder
Assistant Planner
CC: Katie Su, 21087 Grenola Drive, Cupertino, CA 95014
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • build ina(d.)cupertino.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#
nn. 326 oog 13v2ouo)
OWNER�4& OWNER ADDRESS
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.)
B1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner
Buiider" 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.
_J� 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 IV 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.
_� -4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tot I 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.
__L6. 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.
48. 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.
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.
�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.
�12; 1.agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the.,
information 1. 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: 1 -, j
--
-------------------------------------------------------------------------------------------------------------------------------------------
(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-Bbilder 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 owners 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:
OwnerBuilderForin 2010.doc revised 04/14/10