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HomeMy WebLinkAbout2238 PACIFIC AVE - Building Permits CITY OF COSTA MESA • 4L0`'T1 Ws. BUIbDING DIVISION Ji ,l l 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us I FOR INSPECTIONS CALL: (714)754-5626 ° PERMIT NUMBER: 811-00284 PERMIT TYPE B_ROOF2 STATUS: ISSUED APN: 42207108 DATE ISSUED: 09/0712011 ISSUED BY: RMD JOB ADDRESS",2238,P,ACIFICAVjCM„ Suite/Unit: Vicinity: UNITS A AND B-ATTACHED. - ^.a-L—citc Squares: 3000 Valuation: $6,800.00 SCOPE OF WORK: TEAR OFF EXISTING ROOF.COVER WITH 30 YEAR COMP SHINGLES. REPAIR/REPLACE SHEATHING AS NECESSARY. ROOF PITCH IS 4:12. INCLUDES ATTACHED GARAGE. INCLUDES: UNITS A AND B. UNITS ARE ATTACHED.APPROX 3000 SQ FT. NOTE:RESIDENTIAL RE-ROOF: Final approval of permit shall not be granted until access to dwelling unit(s) is provided for verification of the installation of smoke and carbon monoxide alarms by the City Inspector. See Attachment w/Inspection Card OWNER: REIOUX, BARRY J AND PAULINE Address: 3131 MADEIRA Unit: PHONE: City/State/Zip: COSTA MESA,CA - APPLICANT: WU, JOHN Address: 34 WYOMING Unit: : PHONE: 949.678-5882 City/State/Zip: IRVINE, CA ' CONTRACTOR: OWNER-BUILDER License No. 000000 Address: Unit: PHONE: City/State/Zip: • CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: FEE SUMMARY Reroof Plan Check: $0.00 Reroof Permit Fee: $139.25 Reinspection Fee: $0.00 Bldg Std Admin Fund $1.00 TOTAL FEES $140.25 HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 3/18/2010 -PER CMMC Sec. 13-279 Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibitied all hours-Sundays and the following Federal holidays New Years Day,Memorial Day, Independence Day, Labor Day,Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, §1. 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODES. INSPECTION TYPE DATE INTITIALs CODES INSPECTION TYPE DATE INTIIIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof j0'14'It, IE 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy lb 411110 WORKERS'COMPENSATION DECLARATION: Owner ID verified by drivernse. ❑Yes ❑No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ I have and will maintain a certificate of consent to self-Insure for workers' a "� Verification of Ownership by(type of document,i.e.-property tax bill or deed): 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 workers'compensation insurance, as required by • section 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a number are: person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition Carrier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp (ThisseMun nee0nol be completed n'thepermR is valued at one hundred dollars($100)or less) 2,Art 2,Sec.341,Title 8,California Administrative Code). Policy Number: / ❑ As owner-builder, I will not employ anyone to do work which would pJ I'certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of Applicant's Signature Date the Labor Code,I sh-II forthwith comply with these provisions. 'Ilf� —q _ I 1 Division of Industrial Safety Permit Number: A ° -ore ate 1 HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE T• SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes ❑No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. a registration form for acutely hazardous materials? ❑Yes ❑ No Lic.# Class# (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely Contractor's Signature Date hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: temperature and pressure). ❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: ' hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes ❑ No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Govemment Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits). License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): of the California Health and Safety Code). I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other mpensation, WILL DO THE WORK. and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec. 7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? ❑Yes 0 No thereon,and who does such work himself or herself or through his or her own 8 (If"yes", attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the did not.build or improve for purpose of sale.). information given above is correct. I agree to comply with all state taws and .2"1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of Signature Date property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that El I am exempt under sec. the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 1 —1 1 Signature of L awner(s) Date 1 tore Date • l ' i" - 3057-4613/07) And/or,utnoriz/Applicant Date Prescriptive Certificate of Compliance: Residential CF-IR-ALT Residential Alterations Matte 3 of Si . Project Manic: jr K, I Climate Zone/1 „ I it of Stories General information Irina'. i . Site Address: at w3 d rhe_01.--it, Enforcement Agency: 0;.."1„. (fit Hate: if if ii Building Type 0 Single Family 0-Multi Family Circle the Front Orientation:N,E,S,W,or degrees Project Type: 0 Alterations ❑Envelope❑Fenestrations hoof 0 HVAC Conditioned Flom Area(CPA): Replacement or Change Out 0 Duct Replacement 0 Water Heater NOTE: This farm is not to be used.pn'NenJi' Constructed Buildings or Additions • Insulation Values For Opaque Surfaces(for Furring use the Mass and Furring Strips Cansrructimr table below) Assembly Alteration O Opening of framed cavity alone-Alterations/hal involve the opening of the fronted cavity of a wall,ceiling, or floor must install the mandatory minimum i isuloion value pe',(J5f1 for the altered assembly. Fill in Columns A-C and enter mandatary insulation value in Colunm H. ❑Replacement of entire assembly-Replacement of an entire wall, ceiling,or floor assembly requires the installation cif Component Package-D insulation values in Table 151-C. Fill in Columns A-J. • Opaque Surface Details For the furred portioned of Mass Walls see Furring Strips Construction Table below. A ' B C _ U - i E ' ' ' F G H... .1. Q. '1 Proposed 6e hp1 Standard Values From JA4 Table Framing Thickness, I Framed Continuous JA4 Proposed Tag/ Assembly Name Material Spacing, U- JM Table Cavity Insulation Assembly Assembly 3Dt or Type' and Size or Other' factor' Numbers R-values R-Value' Cell Values U-facto? ' Note:For furred assemblies,accounting for Continuous Insulation 17-value,see Page JA4-3 and Equation 4-1. For calculating furred walls use the Mass and +Furring Construction table below ' 1.For Tag/ID indicate the identification name that matches the building plans. 2.Indicate the Assembly Name or type:Roof/Ceiling, Walls,Floors,Slabs, Crawl Spathe,Doors and etc-Indicate the Frame type and Size: For Wood, Metal, Metal Buildings,Mass, enter 2x4,2z6, or etc...see JA4 for other possible frame type assemblies. 3. Enter the thickness for mass in inches or Spacing between framing members enter; 1 Gro'24"OC;or Other for all other assembly description such as Concrete Sandwich Panel,Spandrel Panel,Logs,StrawBale Panel and etc.... 4. Based on the Climate Zone;enter the Standard U-factor from Table 15)-B, C or D for each different assembly Name or type. S.Enter the Table number that closely resembles the proposed assembly. 6. Eine,'the R-value teat is being installed in the wall cavity or between the framing; otherwise, enter "0". 7. Enter the Continuous Insulation It-value for the proposed assembly;otherwise, enter "11“. 8.Enter the rmi'and column of the Lb-facto'value based on Column F Table Number and enter the Assembly (1-facto'in Column J 9,The Proposed Assembly L'-factor Column.1. ;mai be equal to or less than the Standard U-facto•in Column E to comply. • Furring Strips Construction Table for Mass Walls Only A ]i • C D I E _ P C 11 1 1 E L M Proposed Properties of Masonry anti Concrete Added interior or Exterior'insulation Wstils From Reference in Furring Space from Reference Joint Appendix Table 4.3.5,4.3.ü.4.3.7 ,;Mint Appendix Table 4.3,13 , 8; Ln -a n 2” '•uu; y_ O ar.E 4 m • ,, u Ansembly 77,o •- .° 2 t- .' e m,'t 4," a. Final • t. L _ Mas; Nature, .IA4-fublc � ,_ ;, y o B n o - .I _ s Nssemb{y - fhietutess Type Number' < L 2 _ = t .i I-a. u`. i , e < • u e'_ U-luctorC'a Comment \ I . • ,1 • u.•..o.s•..11tfol Mini bp r* IIegi.,•natinu Dane/Trine: HERS Provider: Prescriptive Certificate of Compliancy 'sidentinl CF-}.}2-AL,T' Residential Alterations (Page 3 of 5) Project Nome: Climate'Lane it /r^ It af`Storias - • ROOFING PRODUCTS (COOL ROOFS),§1.51()12 /N When the area of exterior roof.surface to be replaced exceeds more than 50%of the existing roof area, or more than 1,00(1,11), whichever is taco, the new roofing area insmI Mae!tire roofing product"Cool Roof'requirements of§1S2(b)1111, 152(0)111/i, or 1.52(b)IHhil, Check applicable rtlternadva or exception below Oho ma!alteration is exempt from the roofing product "Cool Roof"requirements. Note:If any one of the alternatives or exception below is checked, the Aged Solar Reflectance and Thermal Enhance requirements for roofing products to )8(/) arc not applicable. Do not fill table below. 0 Cool Roofs Not Required in Climate Zones 1-12, 14,and 16 with n Low Sloped. Less or 2:12 pitch. nal Roofs Not Required in Climate Zones I through 9 and lb with n Steep-Sloped Roofs(pitch greater that 2:1.2)and product unit weight less than 51b/112. Alternatives to §152(h)11I1 and§152(1 )}I11,Steep-slope roof(pitch > 2:12) ❑ Insulation with a thermal resistance of at least 025 hr•02."F/Bm or at least a 3/4 inch air-space is added to the roof deck over nn attic;or ❑ Existing ducts in the attic arc insulated and sealed according to §151(010;or ❑ In climate zones 10, 12 and 13,with I ft.of free ventilation area of attic ventilation for every 150 f12 of attic floats area,and where at least 30 percent of the free ventilation area is within 2 feet vertical distance of the roof ridge;or ❑ Building has at least It-30 ceiling insulation;or ❑ Building has radiant barrier in the attic meeting the requirements of'§I 51(02;or ❑ Building has no ducts in the attic;or CI In climate zones IC, 1 1, 13 and 14, R-3 or greater roof deck insulation above vented attic. Exception to §152(b)1}1lii, Low-slope roof(pitch <2:12) ❑ Building ha:;no ducts in the attic. Other Exceptions . C1 Roofing area covered by building integrated;photovoltaic panels and solar thermal panels arc exempt from the below Cool Roof criteria. 0 Roof constructions that have thermal mass over the roof membrane with at least 25 Ib/ft2 is exempt from the below Cool Roof criteria, -I Note: If no CRRC-I label is available,this compliance method cannot be used,use the Performance Approach to show compliance,otherwise, ` Check the applicable box below if Exempt from the Roofing Products"Cool Roof' Requirement: Roof Slope Product Weight Product Aged Solar Thermal C:ILRC Product IU Number < 2:12 >2:12 < 51b/ft2 > 5Ib/fl2 Type' Reflectance'' Eminence SRI3 o ❑ I ❑ 0 on 101E3 ❑I I 1 0 1 ❑ 1 0 1 ❑4 • 1 ❑ 0 0 0 ❑^ ❑ ❑ ❑ 0 ❑^ 1 _ I. The CR/2C Product ID Number can be obtained from the Cool Roof Rating Council's Rated Product Directory at www.coahpafs.ory/Products/sem'ch.nhn 2. Indicate the type of product is being used far the roof top i.e.single-ply roof asphalt roof,metal roof etc. 3. If the Aged Reflectance is not available in.the Cool Roof Rating Council's Rated Product Directory then use the Initial Reflectance value from the sane directory and use the equation(0.2.0.7(pwiaur-0.2)to obtain a calculated aged value. Where p is the Initial Solar Reflectance. 4. Check box if the Aged ReRedonce is a calculated value using the equation above. 5. Calculate the SRI value by using dee SRI- Worksheet at IMM:/Amvw.enerrv.ca.gov/11de24/and enter the resulting value in the SRI Column above and attach&copy of the SRI- Worksheet to the CF-IR. To apply Liquid Field Applied Coatings,the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage recommended by the coatings manufacturer and meet minimum performance requirements listed in§11.1,80)4. Select the applicable coating: U-I ❑ Aluminum-Pigmented Asphalt Roof Coating ❑ Cement-Based Roof Coating Other • • Registration Number: Registration Date/Time: PIERS Provider-: 2008 Residential Compliance Forms August 2009 1 • Prescriptive Certificate of Complistce: Residential CF-1)'t-ALT Residential Alterations (Pare 5 of 5) Projeel Nanre: Climate Zone V 1V.• cif Stories- BEES VERIFICATION SUMMARY The enforcement agency should pm•s:ecial anennon us ihr HERS Measures specified ur this checklist below A completed and signed CF'-4k Form fm•all the meatur•er specified shall be submitted In the building inspector before final ihspeciimh. Duct Scaling & Testing HERS veri/icalico is reguirea,for This meat-tire. • ID YES D NO YES:In Chaste Zones 2 and 9-16,if more Thal,40 linear feel of new or replacement ducts are installed in unconditioned space,the ducts arc to be sealed per 1152(b)IDii and the newly installed duos are to be insulated pet 11151(1:.11 0. ❑ EXCEPTION:Existing duel systems that are extended, which arc constructed,insulated or sealer) with asbestos. O YES 0 NO YES:In Climate Zones 2 and 9-16, if the existing space-conditioning system(HVAC equipment and ducting')is replaced,the ducts are to be sealed per 1152(h)1Di. • ❑YES D NO YES:In Climate Zones 2 and 9-16,if the existing NYAC equipment is replaced(including the replacement of the air handler, outdoor condensing unit of a split system,cooling or heating coil,or the furnace heal exchanger)the ducts are to he sealed per 1520911E. ❑ EXCEPTION:Duct systems that are documented to have been previously sealed confirmed through HERS • verification in accordance with procedures in the Reference Residential Appendix RAS. ❑ EXCEPTION:Duet systems with less than 40-linear feet in unconditioned space. , ❑ EXCEPTION: Existing duet systems constructed,insulated or sealed with asbestos. Refrigerant Charge- Split System HERS verification is required jar this measure. D YES ❑NO YES:In Climate Zones 2 and g-15,when the existing HVAC equipment it replaced(including the replacement of the air handler,outdoor condensing unit of a split system A/C or heat pump,coaling or heating coil, or the furnace heat exchanger)a refrigerant charge.measurcntent shall be verified per§1521b11F. Central Fan Integrated (CFI)Ventilation System and Fan 'Watt Draw _The ventilation requirements of§l50(0 do not amolt to existing residential homes. Ducted Split Systems-Air Conditioners and Heat Pumps. Airflow HERS veri/ication is required jar this measure. D YES 0 NO YES:In Climate Zones 10 through 15,when the existing space-conditioning system(HVAC equipment and ducting)is replaced,the airflow and fan watt draw shall be verified ver§152(b)1 Ci to meet the renuirements of§I 51(f l7B. • Documentation Author's Declaration Statement •• 1 certify that this Certificate of Compliance documentation is.accurnte and complete. Name: Signature: • Company: st\. V\ Date: g — 9- -II Address: 4 \ V✓ " I V` II(Certification Applicablre 0 CEA or 0 CEPS ertification/J): City/Smut/Zip: SVIVC1 CA 01 Z- O.4 Phone: 041) 6i8- o kz Respoitsihle Building Designer's Declaration Staleniett • I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on this Certificate of Compliance. • 1 certify that the energy lecture::and performance specification:for the building design identified on this Certificate of Compliance conform to the requirements ol'Title 21,Parts l and 6 of the California Cotte of Regulations. • The building design feature::identified on this Certificate of Complia nee are cunsistenl with the information provider)to document this building design on the other applicable compliance 1 oras,worksheets,calculations,plunk std specifications submitted us the enforcement agency lot approval with this;huiltlin;r permit application. Name: Signature: , Company: Date: Address: License: City/State/Zip: Phone: Tor asa•isvunee or question:. regarding the Energy Sinntlm•ds, sonnet the Energy Hotline hitt )-8110-772-:;3(10. $ t-8. 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. ➢=i -9. 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.cslb.ca.gov for more information about licensed contractors. • 110. I 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 following address: 11. 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. B :P. 12. I 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. 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:.1A copy of the.property owner's driver's license, form notarization or other verification acceptable to the agency is required to be presented when the permit i sued verify the r y owner's signature. Signature of property owner ��/(/>/ &I:4y Date: I - —t , 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): RC. - Roof.!t t Project Location or Address: 22- 3R I ' (4 A `, , lg, 224-0 *A / B• C - 7 Name of Authorized Agent: 0-0('1`J k.d U Tel No 041 41- " PR 2- Address Address of Authorized Agent: 34- vv YD M 1 N C1 , I�� Iv C CA 612601, 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 owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signat -. f Property Owner's Signature: • �• q' Date: t" —11 3148-30 CALBO Jan 1,2009 OB Packet template 2 of 2