HomeMy WebLinkAbout1265 CYNTHIA LN; ; CBR2023-0554; PermitBuilding Permit Finaled
Residential Permit
Print Date: 05/15/2023
Job Address:
Permit Type:
Parcel#:
Valuation:
Occupancy Group:
#of Dwelling Units:
Bedrooms:
Bathrooms:
Occupant Load:
Code Edition:
Sprinkled:
Project Title:
1265 CYNTHIA LN, CARLSBAD, CA 92008-1506
BLDG-Residential Work Class:
1562311200 Track#:
$24,000.00 Lot#:
Project#:
Plan#:
Construction Type:
Orig. Plan Check#:
Plan Check#:
Cogen
Permit No:
Status:
{city of
Carlsbad
CBR2023-0554
Closed -Finaled
Applied: 02/08/2023
Issued : 02/18/2023
Finaled Close Out: 05/15/2023
Final Inspection: 03/08/2023
INSPECTOR: de Roggenbuke, Dirk
Description: RESIDENTIAL ROOF-MOUNTED SOLAR PV, 6.0KW, 15 MODULES WITH MICROINVERTERS. (E-REVIEW)
Applicant:
MIGUEL RODRIGUEZ
1300 N JOHNSON AVE, # STE 104
EL CAJON, CA 92020-1654
(858) 564-8032
FEE
SB1473-GREEN BUILDING STATE STANDARDS FEE
SOLAR-RESIDENTIAL: per kW
STRONG MOTION -RESIDENTIAL (SMIP)
Total Fees : $293.12 Total Payments To Date: $293.12
Contractor:
SUNLIGHT SOLAR INC
1300 N JOHNSON AVE, # STE 104
EL CAJON, CA 92020-1654
(858) 564-8032
Balance Due:
AMOUNT
$1.00
$289.00
$3.12
$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 "fees/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 ---------
Est. Value
PC Deposit ---------
Date __ 0_2_.o_s_._2_02_3 __ _
Job Address 1265 Cynthia Ln, Carlsbad CA, 92008 Suite: APN: 156 -231 -12 -00 -----
CT/Project#: __________________ Lot#: ___ _
Fire Sprinklers: 0 YES ®) NO Air Conditioning: Q YES @ NO Electrical Panel Upgrade: 0 YES @ NO
BRIEF DESCRIPTION OF WORK:
Residential Roof Mounted Solar PV, 6.0kW, 15x400W with microinverters. NO main panel upgrades.
[Z] Addition/New: _____ Living SF, ___ Deck SF, ___ Patio SF, ___ Garage SF
Is this to create an Accessory Dwelling Unit? 0 Y @ N New Fireplace? 0 Y @ N, if yes how many? __
D Remodel: ____ SF of affected area Is the area a conversion or change of use? 0 Y @ N
0 Pool/Spa: ____ SF Additional Gas or Electrical Features? ____________ _
[l)Solar: 6.0 KW, 15 Modules, Mounted:@ Roof 0 Ground, Tilt:O Y@) N, RMA:OY@>N,
Battery:O Y @ N, Panel Upgrade: Q y @ N
D Reroof: _________________________________ _
D Plumbing/Mechanical/Electrical Only: _______________________ _
D Other: _________________________________ _
APPLICANT (PRIMARY CONTACT)
Name: Ramon Brizo
Address: 1300 N Johnson Ave, Suite 104
City: El Cajon State: CA Zip: 92020
Phone: 8585648032
Email: eq@sunlight4solar.com
DESIGN PROFESSIONAL
Name: _________________ _
Address: ________________ _
City: ________ State: ___ Zip: ___ _
Phone: ________________ _
Email: _________________ _
Architect State License: ___________ _
PROPERTY OWNER
Name: LaDonna Anderson
Address: 1265 Cynthia Ln
City: Carlsbad
Phone: 9189142149
State: CA Zip: _9_2_00_8 __ _
Email: ____________________ _
CONTRACTOR BUSINESS
Name: Sunlight Solar Inc
Address: 1300 N Johnson Ave Suite 104
City: El Cajon State: CA Zip: _9_20_2_0 ___ _
Phone: 858-564-8032
Email: eq@sunlight4solar.com
State License: 997589 Bus. License: -------
(Sec. 7031.S Business and Professions Code: Any City or County which requires a permit to construct, alter, improve, demolish or repair any structure, prior to its
issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law
{Chapter 9, commending with Section 7000 of Division 3 of the Business and Professions Code} or that he/she is exempt therefrom, and the basis for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars {$500)).
1635 Faraday Ave Carlsbad, CA 92008 Ph: 760-602-2719 Fax: 760-602-8558 Email: Building@carlsbadca.gov
8-1 Page 1 of 2 Rev. 06/18
( OPTION A): WORKERS'COMPENSATION DECLARATION:
I hearby affirm under penalty of perjury one of the following declarations:
D I 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.
IZ] 1 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: Insurance Company Name: TECHNOLOGY INSURANCE COMPANY INC
Policy No. TWC4138698 Expiration Date: _o_s_.1_3._20_2_3 ______ _
D Certificate of Exemption: 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 be come
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 civil fines up to $100,000.00, in addition the to the cost of compensation, damages as provided for in Section 3706 of the Labor Code,
interest and attorney's fees.
CONTRACTOR SIGNATURE: ___ ~ ____ n, __ f3_1L;-if-·.,...&-_______ □AGENT DATE: _02_.o_s.2_02_3 ___ _
( OPTION B ): OWNER-BUILDER DECLARATION:
I hereby affirm that I am exempt from Contractor's License Law for the following reason :
D 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 apply 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).
D I, 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 contractor(s) licensed
pursuant to the Contractor's License Law).
D I am exempt under Section ________ Business and Professions Code for this reason:
1. I personally plan to provide the major labor and materials for construction of the proposed property improvement. Q YES O NO
2. I (have/ have not) signed an application for a building permit for the proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction (include name address/ phone/ contractors' license number):
4. I plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work (include name/ address/ phone/
contractors' license number):
5. I will provide some of the work, but I have contracted (hired) the following persons to provide the work indicated (include name/ address/ phone/ type of work):
OWNER SIGNATURE: □AGENT DATE: _____ _ --------------------------
CONSTRUCTION LENDING AGENCY. IF ANY:
I hereby affirm that there is a construction lending agency for the performance of the work this permit is issued (Sec. 3097 (i) Civil Code).
Lender's Name: _____________________ Lender's Address: ____________________ _
ONLY COMPLETE THE FOLLOWING SECTION FOR NON-RESIDENTIAL BUILDING PERMITS ONLY:
Is the applicant or future building occupant required to submit a business plan, acutely hazardous materials registration form or risk management and prevention
program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act? Yes / No
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? Yes / No
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? Yes / No
IF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE
REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT.
APPLICANT CERTIFICATION:
I certify that I have read the application and state that the above information is correct and that the information on the plans is accurate. I agree to comply with all
City ordinances and State laws relating to building construction.
I hereby authorize representative of the City of Carlsbad to enter upon the above mentioned property for inspection purposes. I ALSO AGREE TO SAVE, INDEMNIFY AND KEEP
HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGMENTS, COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF
THE GRANTING OF THIS PERMIT.OSHA: An OSHA permit is required for excavations over 5'0' deep and demolition or construction of structures over 3 stories in height.
EXPIRATION: Every permit issued by the Building Official under the provisions of this Code shall expire by limitation and become null and void if the building or work authorized
by such permit is not commenced within 180 days from the date of such permit or if the building or work authorized by such permit is suspended or abandoned at any time
after the work is commenced for a period of 180 days (Section 106.4.4 Uniform Building Code).
APPLICANT SIGNATURE: ---~ ____ n, __ f3_1L;_o....,,,..,· ~&' __________ DATE: 02.os.2023
1635 Faraday Ave Carlsbad, CA 92008
B-1
Ph: 760-602-2719 Fax: 760-602-8558
Page 2 of 2
Email: Building@carlsbadca.gov
Rev. 06/18
Building Permit Inspection History Finaled
{city of
Carlsbad
PERMIT INSPECTION HISTORY for (CBR2023-0554)
Permit Type:
Work Class:
Status:
Scheduled
Date
03/08/2023
BLDG-Residential Application Date: 02/08/2023
Cogen Issue Date: 02/18/2023
Closed -Finaled Expiration Date: 09/05/2023
IVRNumber: 46482
Actual Inspection Type
Start Date
Inspection No. Inspection
Status
03/08/2023 BLDG-35 Solar Panel
Checklist Item
204942-2023
COMMENTS
Passed
BLDG-Building Deficiency
NOTES Created By
Angie Teanio
TEXT
619-715-8383 Ivan
BLDG-Electric Meter
Release
205083-2023 Passed
Checklist Item COMMENTS
BLDG-Building Deficiency
BLDG-Final Inspection 204943-2023 Passed
Checklist Item
BLDG-Building Deficiency
BLDG-Structural Final
BLDG-Electrical Final
NOTES Created By
Angie Teanio
COMMENTS
TEXT
619-715-8383 Ivan
Wednesday, March 8, 2023
Owner:
Subdivision:
Address: 1265 CYNTHIA LN
CARLSBAD, CA 92008-1506
Primary Inspector Reinspection Inspection
Dirk de Roggenbuke
Dirk de Roggenbuke
Dirk de Roggenbuke
Passed
Yes
Created Date
03/07/2023
Passed
Yes
Passed
Yes
Yes
Yes
Created Date
03/07/2023
Complete
Complete
Complete
Page 1 of 1
C cityaf
Carlsbad
PURPOSE
CLIMATE ACTION PLAN
CONSISTENCY CHECKLIST
B-50
Development Services
Building Division
1635 Faraday Avenue
(760) 602-2719
www.carlsbadca.gov
This checklist is intended to assist building permit applicants identify which Climate Action Plan (CAP) ordinance
requirements apply to their projects. The completed checklist must be included in the building permit application. It may be
necessary to supplement the completed checklist with supporting materials, calculations or certifications, to demonstrate
full compliance with CAP ordinance requirements. For example, projects that propose or require a performance approach
to comply with energy-related measures will need to attach to this checklist separate calculations and documentation as
specified by the ordinances.
NOTE: The following type of permits are not required to fill out this form
❖ Patio I ❖ Decks I ❖ PME (w/o panel upgrade) I ❖ Pool
..iii If an item in the checklist is deemed to be not applicable to a project, or is less than the minimum required by ordinance,
an explanation must be provided to the satisfaction of the Building Official.
..iii Details on CAP ordinance requirements are available on the city's website .
..iii A CAP Building Plan template (form B-55) shall be added to the title page all building plans. This template shall be
completed to demonstrate project compliance with the CAP ordinances. Refer to the building application webpage and
download the latest form.
Application Information
Project Name/Building
Permit No.: BP No.:
PropertyAddress/APN : 1265 Cynthia Ln, Carlsbad CA, 92008 / 156-231-12-00
Applicant Name/Co.: Sunlight Solar Inc
ApplicantAddress: 1300 N Johnson Ave Suite 104, El Cajon CA, 92020
Contact Phone: 858-564-8032 Contact Email: eq@sunlight4solar.com
Contact information of person completing this checklist (if different than above):
Name:
Company
name/address:
Applicant Signature:
B-50
Same Contact Phone:
Contact Email:
~n., J3~ Date: 02.08.2023
Page 1 of 6 Revised 08/19
City of Carlsbad Climate Action Plan Consistency Checklist
Use the table below to determine which sections of the Ordinance Compliance checklist are applicable to your project.
For alterations and additions to existing buildings, attach Building Permit Valuation worksheet.
Building Permit Valuation (BPV) from worksheet: $ _____ _
Construction Type
[Z] Residential
□ New construction
□ Additions and alterations:
IZI BPV < $60,000
□ BPV ~ $60,000
□ Electrical service panel upgrade only
□ BPV ~ $200,000
D Nonresidential
□ New construction
□ Alterations:
□ BPV ~ $200,000 or additions ~ 1,000
square feet
□ BPV ~ $1,000,000
□ ~ 2,000 sq. ft. new roof addition
Checklist Item
Complete Section(s) Notes:
A high-rise residential building is 4 or more stories, including a
Low-rise High-rise mixed-use building in which at least 20% of its conditioned floor
area is residential use
2A, 3A, 1B, 2B,
4A 3B,4A
N/A N/A All residential additions and alterations
1A, 4A 4A 1-2 family dwellings and townhouses with attached garages
only
*Multi-family dwellings only where interior finishes are removed
1A, 4A* 1B, 4A* and significant site work and upgrades to structural and
mechanical, electrical, and/or plumbing systems are proposed
1 B, 2B, 3B, 4B and 5
1B, 5
1B, 2B, 5 Building alterations of~ 75% existing gross floor area
2B, 5 1 B also applies if BPV ~ $200,000
CAP Ordinance Compllance
Check the appropriate boxes, explain all not applicable and exception ~ems, and provide supporting calculations and documentation as necessary.
1. Energy Efficiency
Please refer to Carlsbad Municipal Code (CMC) sections 18.21 .155 and 18.30.190, and the California Green Building Standards Code (CALGreen) for
more information when completing this section.
A D Residential addition or alteration ~ $60,000 building pennit valuation. □ NIA ----------See CMC section 18.30.190. □ Exception: Home energy score~ 7
( attach certification)
Year Built Single-family Requirements Multi-family Requirements
□ Before 1978 Select one:
□ Duct sealing □ Attic insulation □Cool roof □ Attic insulation
□ 1978 and later Select one:
□ Lighting package □ Water heating Package
□ Between 1978 and 1991 Select one:
□ Duct sealing □ Attic insulation □Cool roof
□ 1992 and later Select one:
□ Lighting package □ Water heating package
B. D Nonresidential* new construction or alterations ~ $200,000 building pennit valuation,
or additions ~ 1,000 square feet □ NIA
Updated 8/15/2019 2
City of Carlsbad Climate Action Plan Consistency Checklist
See CMC 18.21.155 and CALGreen Appendix AS, Division AS.2 -Energy Efficiency.
AS.203.1.1 Choose one: □ .1 Outdoor lighting □ .2 Warehouse dock seal doors
□ .3 Restaurant service water heating (comply with Caliomia Energy Code section 140.5, as amended) □ NIA ----------□ .4 Da~ight design PAFs □ .5 Exhaust air heat recovery
AS.203.1.2.1
Choose one as applicable: □ .95 Energy budget □ .90 Energy budget □ NIA
AS.211.1**
□ On-site renewable energy □ NIA
AS.211 .3**
□ Green power (if offered by local utility provider, 50% minimum renewable sources) □ NIA
AS.212.1
□ Elevators and escalators □ NIA
AS.213.1
□ Steel framing □ NIA
* lndudes hotels/motels and high-rise residential buildings
** For alterations.: $1,000,000 BPV and affecting > 75% existing gross floor area, or alterations that add 2,000 square feet of new roof addition: comply
with CMC 18.30.130 instead.
2. Photovoltaic Systems
A. [Z] Residential new construction (for low-rise residential building permit applications submitted after 1/1/20). Refer to 2019 California
Energy Code section 150.1(c)14 for requirements. Notes: 1) High-rise residential buildings are subject to nonresidential photovoltaic
requirement (28 below) instead. 2) If project includes installation of an electric heat pump water heater pursuant to CMC 18.30.150(8)
(high-rise residential) or 18.30.170(8) (low-rise residential), increase system size by .3kWdc if PV offset option is selected.
Floor Plan ID (use additional CFA #d.u. Calculated kWdc*
sheets if necessary)
Total System Size:
kWdc = (CFAx.572) / 1,000 + (1.15 x#d.u.)
*Formula calculation where CFA = conditional floor area, #du = number of dwellings per plan type
If proposed system size is less than calculated size, please explain.
Exception
□
□
□
□
kWdc
8. D Nonresidential new construction or alterations ~$1,000,000 8PV and affecting ~75% existing floor area, or addition that increases roof
area by ~2,000 square feet Please refer to CMC section 18.30.130 when completing this section. Note: This section also applies to
high-rise residential and hotel/motel buildings.
Choose one of the following methods:
□ Gross Floor Area (GFA) Method
GFA:
□If< 1 0,000s.f. Enter: 5 kWdc
Min. System Size:
□If~ 1 0,000s.f. calculate: 15 kWdc x (GFA/10,000) **
__ kWdc
**Round building size factor to nearest tenth, and round system size to nearest whole number.
□ Time-Dependent Valuation Method
Updated 8/15/2019 3
City of Carlsbad Climate Action Plan Consistency Checklist
Annual TDV Energy use:*** ______ x .80= Min. system size: _____ kWdc
*** Attach calculation documentation using modeling software approved by the California Energy Commission.
3. Water Heating
A. D Residential and hotel/motel new construction
Please refer to CMC sections 18.30.150 and 18.30.170 when completing this section.
D For systems serving individual dwelling units choose one:
D Heat pump water heater AND Compact hot water distribution AND Drain water heat recovery (low-rise
residential only)
D Heat pump water heater AND PV system .3 kWdc larger than required in CMC section 18.30.130 (high rise
residential hotel/motel) or CA Energy Code section 150.1 ( c) 14 (low-rise residential)
D Heat pump water heater meeting NEEA Advanced Water Heating Specification Tier 3 or higher
D Solar water heating system that is either .60 solar savings fraction or 40 s.f. solar collectors
D Exception:
D For systems serving multiple dwelling units, install a central water-heating system with all of the following:
D Gas or propane water heating system
D Recirculation system per CMC 18.30.150(8) (high-rise residential, hotel/motel) or CMC 18.30.170(8) (low-
rise residential)
D Solar water heating system that is either:
D .20 solar savings fraction
D .15 solar savings fraction, plus drain water heat recovery
D Exception:
B. D Nonresidential new construction
Please refer to Carlsbad Ordinance CMC section 18.30.150 when completing this section.
D Water heating system derives at least 40% of its energy from one of the following (attach documentation):
D Solar-thermal D Photovoltaics D Recovered energy
□Water heating system is (choose one):
D Heat pump water heater
D Electric resistance water heater(s)
□Solar water heating system with .40 solar savings fraction
□Exception:
Updated 8/15/2019 4
City of Carlsbad Climate Action Plan Consistency Checklist
4. Electric Vehicle Charging
A. D Residential New construction and major alterations*
Please refer to Carlsbad Ordinance CMC section 18.21.140 when completing this section.
D one and two-family residential dwelling or townhouse with attached garage:
D one EVSE Ready parking space required D Exception :
D Multi-family residential: D Exception :
Total Parking Spaces EVSESpaces
Proposed Capable Ready Installed
Calculations: Total EVSE spaces= .10 x Total parking (rounded up to nearest whole number)
EVSE Installed= Total EVSE Spaces x .50 (rounded up to nearest whole number)
EVSE other= Total EVSE spaces -EVSE Installed
(EVSE other may be "Capable," "Ready" or "Installed.")
Total
*Major alterations are: (1) for one and two-family dwellings and townhouses with attached garages, alterations have a building permit valuation ~ $60,000
or include an electrical service panel upgrade; (2) for multifamily dwellings (three units or more without attaclhed garages), alterations have a building permit
valuation ~ $200,000, interior finishes are removed and significant site work and upgrades to structural and mechanical, electrical, and/or plumbing
systems are proposed.
B D Nonresidential new construction (includes hotels/motels) D Exception ·
Total Parking Spaces EVSE Spaces
Proposed Capable I Ready I Installed I Total
10 2 I 5 I 1 I 8
Calculation: Refer to the table below:
Total Number of Parkinq Spaces provided Number of required EV Spaces Number of required EVSE Installed Spaces
□ 0-9 1 1
□ 10-25 2 1
□ 26-50 4 2
□ 51-75 6 3
□ 76-100 9 5
□ 101-150 12 6
□ 151-200 17 9 n 201 and over 10 percent of total 50 percent of Required EV Spaces
Updated 8/15/2019 5
City of Carlsbad Climate Action Plan Consistency Checklist
5. D Transportation Demand Management (TDM): Nonresidential ONLY
An approved Transportation Demand Management (TDM) Plan is required for all nonresidential projects that meet a threshold of employee-generated ADT.
City staff will use the table below based on your submitted plans to determine whether or nor your permit requires a TDM plan. If TDM is applicable to your
permit, staff will contact the applicant to develop a sit&specific TDM plan based on the permtt details.
Acknowledgment:
Employee ADT Estimation for Various Commercial Uses
Use
EmpADTfor
first 1,000 s.f.
EmpADTI
1000 s.f.1
Office (all)2 20
Restaurant 11
Retaib 8
Industrial 4
Manufacturing 4
Warehousin 4
1 Unless otherwise noted, rates estimated from /TE Trip
Generation Manual, 1 (Yh Edition
13
11
4.5
3.5
3
1
2 For all office uses, use SAN DAG rate of 20 ADT/1,000 sf to
calculate employee ADT
3 Retail uses include shopping center, variety store, supermarket,
gyms, pharmacy, etc.
Other commercial uses may be subject to special
consideration
Sample calculations:
Office: 20,450 sf
1. 20,450 sf/ 1000 x 20 = 409 Employee ADT
Retail: 9,334 sf
1. First 1,000 sf = 8 ADT
2. 9,334 sf -1,000 sf = 8,334 sf
3. 8,334 sf/ 1,000 x 4.5 + 8 = 46 Em lo ee ADT
I acknowledge that the plans submitted may be subject to the City of Carlsbad's Transportation Demand Management Ordinance. I agree to be contacted should
my permit require a TDM plan and understand that an approved TDM plan is a condition of permit issuance.
ApplicantSignature: __ ~ ____ n,,-__ ;3_7}-r-1. _'6 _____ _ Date: 02.08.2023
Person other than Applicant to be contacted for TDM compliance (if applicable):
Name(Printed): Not Applicable Phone Number: ____ _
Email Address: __________________ _
Updated 8/15/2019 6