HomeMy WebLinkAbout2360 CIPRIANO LN; ; CBR2022-2063; PermitBuilding Permit Finaled
Residential Permit
Print Date: 01/20/2023
Job Address: 2360 CIPRIANO LN, CARLSBAD, CA 92008-1006
Permit Type: BLDG-Residential
Parcel#: 1560320800
Valuation: $10,654.65
Occupancy Group:
#of Dwelling Units:
Bedrooms:
Bathrooms:
Occupant Load:
Code Edition:
Sprinkled:
ProjectTitle:
Work Class: Alteration
Track#:
Lot#:
Project#:
Plan#:
Construction Type:
Orig. Plan Check#: CC2022-0221
Plan Check#:
(city of
Carlsbad
Permit No: CBR2022-2063
Status: Closed -Finaled
Applied: 06/14/2022
Issued: 12/01/2022
Finaled Close Out: 01/20/2023
Final Inspection: 01/11/2023
INSPECTOR: Alvarado, Tony
Renfro, Chris
Description: 2360 CIPRIANO: (CC2022-0221) NEW (405 SF) DECK, EXISTING COVERED PORCH ENCLOSURE (150 SF) UNCONDITIONED
SPACE
FEE
BUILDING PLAN CHECK
DECKS/BALCONY-NEW/REPLACE
Property Owner:
CO-OWNERS HARTMAN GREG AND LUCIA
2360 CIPRIANO LN
CARLSBAD, CA 92008
SB1473 -GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION -RESIDENTIAL (SMIP)
Total Fees: $1,363.64 Total Payments To Date: $1,363.64 Balance Due:
AMOUNT
$536.25
$825.00
$1.00
$1.39
$0.00
Please take NOTICE that approval of your project includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter
collectively referred to as 11fees/exaction." You have 90 days from the date this permit was issued to protest imposition of these
fees/exactions. If you protest them, you must follow the protest procedures set forth in Government Code Section 66020(a), and file the
protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section
3.32.030. Failure to timely follow that procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their
imposition.
You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection
fees and capacity changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this
project. NOR DOES IT APPLY to any fees/exactions of which you have previously been given a NOTICE similar to this, or as to which the
statute of limitation has previously otherwise expired.
Building Division Page 1 of 1
1635 Faraday Avenue, Carlsbad CA 92008-7314 I 442-339-2719 I 760-602-8560 f I www.carlsbadca.gov
( City of
Carlsbad
RESIDENTIAL
BUILDING PERMIT
APPLICATION
B-1
Plan Check ~ BA 2oZ.2-2 o{J
Est. Value-# IO J (p~ f,5"
PC Deposit ,¥ £3 &, • Z~
Date 6 -/"'(-U'Z-2--
Job Address 2360 CIPRIANO LANE Unit: APN: 156-032-08-00 ----~
CT /Project #:_M_A_P_4_66_2 ______________ lot #: 8 Year Built: _1_96_3 _______ _
BRIEF DESCRIPTION OF WORK: 150 S.F. EXISTING COVERED PORCH ENCLOSURE ( UNCONDITIONED SPACE)
405 S.F. NEW DECK Coo<Z, ~~ cc.. ·zo 22 -0 2.Z \
§] New SF: Living SF, ____ Deck SF, 405 Patio SF, 150 Garage SF __ _
Is this to create an Accessory Dwelling Unit? O Y O N New Fireplace? O YC:) N, if yes how many? ___ _
D Remodel: _____ SF of affected area Is the area a conversion or change of use? O YO N
0 Pool/Spa: _____ SF Additional Gas or Electrical Features? ____________ _
□ Solar:. ___ KW, ___ Modules, Mounted:0Roof OGround, Tilt: 0 YON, RMA: 0 YO N,
Battery:OYO N, Panel Upgrade: Ov ON Electric Meter number: ------------
0th er:
PRIMARY APPLICANT PROPERTY OWNER
Name: JAMES CHINN Name:GREGORY HARTMAN
Address:2120 JIMMY DURANTE BL. #114 Address:2360 CIPRIANO LANE
City: DEL MAR State:CA Zip:._9_2_01_4 ___ City:CARLSBAD State:CA Zip:_9_20_0_8 __ _
Phone: 858-755-5863 Phone: 760-583-7648
Email:iameschinn400@gmail.com Email: d r:':). h«r-fM<?.,(oe,J ,'VV{~{. L<>M
DESIGN PROFESSIONAL
Name:JAMES CHINN
Address:2120 JIMMY DURANTE BL. #114
City:DEL MAR State:_C_A __ .Zip:92014
Phone: 858-755-5863
Email:Jameschinn400@gmail.com
Architect State License: C-15737 -----------
CONTRACTOR OF RECORD
Business Name:. _______________ _
Address: ________________ _
City: ______ State: __ ~Zip: ______ _
Phone: _________________ _
Email: _________________ _
CSLB License #: ______ Class: ______ _
Carlsbad Business License# (Required): _______ _
APPLICANT CERTIFICATION: I certify that I have read the app//cation and state that the above information · he information of the plans Is accurate. I
agree to comply with all City ordinances and State laws relating to building construction.
NAME (PRINT): JAMES CHINN
1635 Faraday Ave Carlsbad, CA 92008 Ph: 442-339-2719 Email: Building@carlsbadca.gov
REV. 04122
THIS PAGE REQUIRED AT PERMIT ISSUANCE PLAN CHECK NUMBER: _______ _
A BUILDING PERMIT CAN BE ISSUED TO EITHER A STATE LICENSED CONTRACTOR OR A PROPERTY OWNER. IF THE PERSON SIGNING
THIS FORM IS AN AGENT FOR EITHER ENTITY AN AUTHORIZATION FORM OR LETTER IS REQUIRED PRIOR TO PERMIT ISSUANCE.
(OPTION A): LICENSED CONTRACTOR DECLARATION:
I herebyaffirmunderpenaltyof perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3
of the Business and Professions Code, and my license is in full force and effect. I also affirm under penal tyof perjury one of the
fallowing declarations (CHOOSE ONE):
DI have and will maintain a certificate of consent to self-insure for workers' compensation provided by Section 3700 of the Labor Code, for the performance of the
work which this permit is issued. PolicyNo. ____________________________________________ _
-OR-DI have and will maintain worker's compensation, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation insurance carrier and policy number are: lnsuranceCompany Name: -------------------------I
Policy No. _____________________________ Expiration Date: _________________ ,
-OR-
D Certificate of E){emption: 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 workers' compensation Laws of California. WARNING: Failure to secure workers compensation coverage is unlawful and shall subject an employer to
criminal penalties and clvil fines up to $100,000.00, in addition the to the cost of compensation, damages as provided for ln Section 3706 of the Labor Code,
interest and attorney's fees.
CONSTRUCTION LENDING AGENCY, IF ANY:
! hereby affirm that there is a construction lending agency for the performance of the work this permit is issued (Sec. 3097 (i) Civil Cade).
Lender's Name: _______________________ ,Lender's Address: _______________________ _
CONTRACTOR CERT/FICA TION: The applicant certifies that all documents and plans clearly and accurately show all existing and proposed buildings, structures, access roads, and
uttlities/utility Nsements. All proposed modifications and/or additions are clearly labeled on the site plan. Any potentially existing detail within these plans mrnnsistent with the site plan are
not approved for construction and may be required to be altered or removed. The city's approval of the application is based on the premise that the submitted documents and plans show
the correct dimensions of; the property, buildings, structures and their setbacks from property lines and from one another; access roads/cas.emcnts, and utilities. The existing and proposed
use of each building as stated 1s true and correct; all easemenh and other encumbrances to development h;we been accurately shown and labeled as well as all on-site grading/site preparation.
All improvements existing on the property were completed in accordance with all re11ulations in existence at the time of their construction, unless otherwise noted.
NAME (PRINT): _________ SIGNATURE: _________ DATE: _____ _
Note: If the person signing above is an authorized agent for the contract ·d tter of authorization on contractor letterhead.
-OR-
(OPTION B): OWNER-BUILDER DECLARATION:
I hereby affirm that I am exempt from Contractor's License Law for the following reason:
0 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 and Professions Code: The Contractor's license Law does not .ipply to an owner of property who builds or improves thereon, and who does such
work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner-builder will have the burden of proving that he did not build or Improve for the purpose of sale).
-OR-
ti{]J, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The
Contractor's License Law does not apply to an owner of property who builds or improves thereon, and contracts for such projects with cantractor\s) licensed
pursuant to the Contractor's License Law).
-OR-DI am exempt under Business and Professions Code Division 3, Chapter 9, Article 3 for this reason:
ANll.
FORM B-61 "Dwner Builder Acknowledgement and Verification Form" is required for any permit issued to a property owner.
By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the
improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entirety by licensed
contractors, I understand that a copy of the applicable low, Section 7044 of the Business and Professions Code, is available upon request when this application is
submitted or at the following Web site: http: I lwww.leginfo.ca.gov! co/aw. html.
OWNER CERT/FICA TION: The applicant certifies that all documents and plans dearly and accurately show all existing and proposed buildings, structures, access roads, and utilities/utility
easements. All proposed modifications and/or additions are deilrly labeled on the site plan. Any potentially ei,:isting detail w1thm these plans inconsistent with the site plan are not approved
for construction and may be reqLiired to be altered or removed. The city's approval of the application is based on the premise that the submitted documenh and plans show the correct
dimensions of; the property, buildings, structures and their setbacks from proprrty lines and from one another; acct'ss roads/easements, and utilities. The e11isting and proposed use of each
building as stated is true and correct; all easements and other encumbrances to development have been accurately shown and labeled as well as all on-site grading/site preparation. All
improvements existing on the property were completed in accordance with all regulations in existence at
NAME (PRINT): SIGN:
Note: If the erson si nin above Is an authorized a ent for the ro owner.
163S Faraday Ave Carlsbad, CA 92008 Ph: 442-339-2719 Email; Building@carlsbadca.gov
2
REV. 04/22
(city of
Carlsbad
OWNER-BUILDER
ACKNOWLEDGEMENT
FORM
8-61
Development Services
Building Division
1635 Faraday Avenue
442-339-2719
www.carlsbadca.gov
OWNER-BUILDER ACKNOWLEDGMENT FORM
Pursuant to State of California Health and Safety Code Section 19825-19829
To: Property Owner
An application for construction permit(s) has been submitted in your name listing you as the owner--builder of the
property located at:
Site Address
The City of Carlsbad ("City") is providing you with this Owner-Builder Acknowledgment and Verification form
to inform you of the responsibilities and the possible risks associated with typical construction activities issued
in your name as the Owner-Builder.
The City will not issue a construction permit until you have read and initialed your understanding of each
provision in the Property Owner Acknowledgment section below and sign the form. An agent of the owner
cannot execute this notice unless you, the property owner, complete the Owner's Authorized Agent form and
it is accepted by the City of Carlsbad.
INSTRUCTIONS: Please read and initial each statement below to acknowledge your understanding and
verification of this information by signature at the bottom of the form. These are very important construction
related acknowledgments designed to inform the property owner of his/her obligations related to the requested
permit activities.
I. ~I understand a frequent practice of unlicensed contractors 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 contractor 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.
II.
Ill.
IV.
V.
_/,}Yl 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.
_K_i 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. fa I understand contractors are required by law to be licensed and bonded in California and to list their license
n~~b..,,ers on permits and contracts.
LL.,I.._r 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.
1 REV. 05/22
Owner-Builder Acknowledgement Continued
VI.
VII.
VIII.
IX.
X.
XI.
XII.
k_l understand if lam 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. k I 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.
,N_ I understand as an Owner--Builder if I sell the property for which this permit is issued, 1 may be held liable
for any financial or personal injuries sustained by any subsequent owner(s) which result from any latent
construction defects in the workmanship or materials.
_£_ 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.
P, 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:
2~r..o c.'pv;o.,o11,0 L 1,'1-< c.,,✓IJ'1;,J er\ '[t.oocr
Jl!!....1 agree that, as the party legally and financially responsible forth is proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner--Builders as well as employers .
../lJ::..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 Contractor's 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 coverage.
Before a building permit can be issued, this form must be completed, signed by the property owner and returned
to the City of Carlsbad Building Division.
I declare under penalty of perjury that I have read and understand all of the information provided on this form and that my responses, including my
authority to sign this form, is true and correct. I om aware that I have the option to consult with legal counsel prior to signing this form, and I have
either (1) consulted with legal counsel prior to signing this form ar (2) have waived this right in signing this form without the advice of legal counsel.
Property Owner Name (PRINT)
3 REV.05/22
Building Permit Inspection History Finaled
( City of
Carlsbad
PERMIT INSPECTION HISTORY for (CBR2022-2063)
Permit Type: BLDG-Residential Application Date: 06/14/2022 Owner: CO-OWNERS HARTMAN GREG AND
Work Class: Alteration
Status: Closed -Finaled
LUCIA
Issue Date: 12/01/2022 Subdivision: LAS FLORES PLACE
Expiration Date: 06/21/2023
IVR Number: 41286
Address: 2360 CIPRIANO LN
CARLSBAD, CA 92008-1006
Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection
Date Start Date Status
12/02/2022 12/02/2022 BLDG-11 197867-2022 Passed Tony Alvarado
12/23/2022 12/23/2022
01/11/2023 01/11/2023
Friday, January 20, 2023
F ou n dation/Ftg/P iers
(Rebar)
Checklist Item COMMENTS
BLDG-Building Deficiency December 2, 2022:
BLDG-14
Frame/Steel/Bolting/We
lding (Decks)
Checklist Item
1. New attached wood walking deck,
above 30 inches grade level, (seven) total
quantity footing/isolated pad spread
footings, per structural engineers plans
and detail specifications on structural
sheet D -1, detail #3-approved.
199591-2022 Passed Chris Renfro
COMMENTS
BLDG-Building Deficiency
BLOG-Final Inspection 200470-2023 Passed Tony Alvarado
Checklist Item COMMENTS
BLDG-Structural Final
BLDG-Electrical Final
Complete
Passed
Yes
Complete
Passed
Yes
Complete
Passed
Yes
Yes
Page 1 of 1
STORM WATER COMPLIANCE FORM
TIER 1 CONSTRUCTION SWPPP (hf<.~:1-d0Ce3
STORM WATER POLLUTION PREVENTION NOTES BEST MANAGEMENT PRACTICES (BMP) SELECTION TABLE
Erosion Control Sediment Control BMPs Tracking Non-Stonm Water Waste Management and Materials
1. ALL NECESSARY EQUIPMENT AND MATERIALS SHALL BE BMPs Control BMPs Management BMPs Pollution Control BMPs
AVAILABLE ON SITE TO FACILITATE RAPID INSTALLATION C: OF EROSION AND SEDIMENT CONTROL BMPs WHEN RAIN C: C: 0 --0 0 :;:; C: C: "O " "O IS EMINENT. C: :;:; :;:; C1> 0 E C: " "O "' u u C: C: C1> E C: -0 :, :, 0 '6 ·c: C. 0 0 0 E .; L L :;:; L ":, " " ::,; "O "' C1> L --C: >, C1> -2. THE OWNER/CONTRACTOR SHALL RESTORE ALL EROSION C: " L " c "'"' "' ~ '-er L 0 C: "' " C1> C. C: ·c: -Oc, " ·a. ·c: -C: "' C: L w !!i C: 0 C Best Management Practice• o1e! .s C co L 0 " 0 L "' " :;:; ;;::_ "' CONTROL DEVICES TO WORKING ORDER TO THE SATISFACTION "''" "' ,= " 0 C: 0 " -" C -o-.c C: E " C1> ·5 C
UL "' "O "' ~ "O Q) "' ::,; C: " C: C: ;;:: C: (BMP) Description ➔ "' u "u, -~ "' C1> co C1> C: C: !!i -" "' " " OF THE CITY INSPECTOR AFTER EACH RUN-OFF PRODUCING " " '" C: C: C: Cl :::, :, ~ (l,) u -0 0 0 L 0 ~~ "O >, 0"' 0 " [!l E " E " E :;:; C: Cl co U,·-C1> O:;:; 0 " C 0 C1> " RAINFALL. X ::,; Cl c,, Cl C: " "' E C ~~ i!l 0 u en:;:; " " C:
0., 0 ~ L-;;:: " 0 " -" C ~ .co< -:, ..0 E al :=3: :0 u·c ·-C1> ·c: (L 0 C1> ~ C1> 1:' C1> " " E 1 L"-C: 0 L 0 .co< L "O .c C: u L " :, "O :o E ·-"O 2 t.i " "O 0 oc U D -C. L-..0 D •-L 0 a, L u ~§ 0 0 t: ·o '6 " " " u C: 1; ~ -·-C -o -·-C: N C: C: C: 3. THE OWNER/CONTRACTOR SHALL INSTALL ADDITIONAL EROSION 0 -~ ..s e 0 C1> .B 0 D 0 .c " 0 " ~ OL " .c ..0 L 0 D 0 ~u o_ 0 -c,O CC 0 D "' W Cl in en u, 0 [;:: "' U) > u, "' (L UJ C: u, "' ;;:: ct <LO (L ::,; u, ::,; u, "'0 u,::,; :,: ::,; 0 ::,; CONTROL MEASURES AS MAY BE REQUIRED BY THE CITY
INSPECTOR DUE TO INCOMPLETE GRADING OPERATIONS OR CASOA Designation ➔ r--<X) 0, .... <X) 0 N "' r--<X) N "' .... co (0 <X) 7 -"' co (0 r--7 I I I I I I I I I I I I I I I I I I I I I I I UNFORESEEN CIRCUMSTANCES WHICH MAY ARISE. 0 0 0 0 w w w w w w w w ~ ~ u, u, u, u, ::,; ::,; ::,; ::,; ::,; ::,; ::,; Construction Activity w w w w u, u, u, u, en en en en z z z z ;;:: ;;:: ;;:: ;;:: ;;:: ;;:: ;;::
4. ALL REMOVABLE PROTECTIVE DEVICES SHALL BE IN PLACE Gradinn /Soil Disturbance -
AT THE END OF EACH WORKING DAY WHEN THE FIVE (5) Trench inn /Excavation )5
DAY RAIN PROBABILITY FORECAST EXCEEDS FORTY PECENT Stockoilina X ( 40%). SILT AND OTHER DEBRIS SHALL BE REMOVED AFTER Drill inn IBorina
EACH RAINFALL. Concrete/Asohalt Sawcuttina
5. ALL GRAVEL BAGS SHALL CONTAIN 3/4 INCH MINIMUM Concrete Flatwork ;,<..
Pavina AGGREGATE. Conduit/Pine Installation
6. ADE QUA TE EROSION AND SEDIMENT CONTROL AND PERIMETER Stucco/Mortar Work
PROTECTION BEST MANAGEMENT PRACTICE MEASURES MUST Waste Disoosal X ,<.
BE INSTALLED AND MAINTAINED. Staainn/Lav Down Area
Eauioment Maintenance and Fuelinn -7. THE CITY INSPECTOR SHALL HAVE THE AUTHORITY TO ALTER Hazardous Substance Use/Storaae -x V THIS PLAN DURING OR BEFORE CONSTRUCTION AS NEEDED Dewaterina
TO ENSURE COMPLIANCE WITH CITY STORM WATER QUALITY Site Access Across Dirt
REGULATIONS. Other /list\:
Instructions:
1. Check the box to the left of all applicable construction activity (first column) expected to occur during construction.
2. Located along the top of the BMP Table is a list of BMP's with it's corres\londing California Stormwater Quality Association (CASQA) designation number. Choose one
or more BMPs you intend to use during construction from the list. Check he box where the chosen activity row intersects with the BMP column.
3. Refer to the CASQA construction handbook for inforr1ation and details of the chosen BMPs and how to apply them to the project.
OWNER'S CERTIFICATE:
I UNDERSTAND AND ACKNOWLEDGE THAT I MUST: (1) IMPLEMENT RtcE.\\/t-0 BEST MANAGEMENT PRACTICES (BMPS) DURING CONSTRUCTION PROJECT INFORMATION ACTl~TIES TO THE MAXIMUM EXTENT PRACTICABLE TO AVOID LN-THE MOBILIZATION OF POLLUTANTS SUCH AS SEDIMENT AND TO 1-\ 14: l\\11 Site Address: z__3c:,.o ('.__1 ff'-(~ ,u AVOID THE EXPOSURE OF STORM WATER TO CONSTRUCTION ' 513/>D ffv>. osz-o~-02> RELATED POLLUTANTS; AND (2) ADHERE TO, AND AT ALL TIMES, -r f,J:,.l N
r-f\'{ Or.': ,,\\J\S\0 Assessor's Parcel Number: COMPLY WITH THIS CITY APPROVED TIER 1 CONSTRUCTION SWPPP
THROUGHOUT THE DURATION OF THE CONSTRUCTION ACTI~TIES ,._, 01\--l'--" '--' -Emergency Contact:
UNTIL THE CONSTRUCTION WORK IS COMPLETE AND APPROVED e,\.l I l
Name:G/,€4. ~/:v>
BY THE CITY OF CARLSBAD.
24 Hour Phone: 7 Ce9 -)8 3 ' 7 G, '--( i1 I C/.-\1 ~,.., ~ (q~~
OWN~)/] ~ Y.N,J (PRINT)
~1-
Construction Threat to Storm Water Quality
(Check Box) G'J.
OWNER~S AGENT NA'ME (SIGNATURE) A 0 MEDIUM W I E-29 Page 1 of 1 V
REV 11/17