HomeMy WebLinkAboutPMTC2021-00064 ApplicationL
NTYAN LUIS
OBISPO
PROPERTY INFORMATION
COUNTY OF SAN LUIS OBISPO
DEPARTMENT OF PLANNING & BUILDING
Construction Permit Application
Assessor Parcel Number(s): 073-341-0008
Address:
Parcel Size 18.67 acres
APPLICANT/PROFESSIONAL INFORMATION (Select Contact type Agents need Consent of Property Owner form)
❑ Landowner Name: Scott D. and Barbara Stimson
Mailing Address:
Email:
2100 Slack Street, San Luis
CA 93405
Phone: _
❑ Licensed Professional Jacobs Telecommunications, Inc. Phone: #
Mailing Address: 2600 Michelson Drive, Suite 500, Irvine, CA 92612
License #: Sean O'Sullivan, P.E. # C84392 Email: sean.osullivan2@lacobs.co
❑ Licensed Contractor TBD Phone:
Mailing Address:
License #:
17 Agent for O Contractor OR ❑ Owner:
Email:
Mailing Address: 2600 Michelson Drive, Suite 500, Irvine, CA 92612
Email: amy.dresch@jacobs.com Phone:
244-7604
Inc.
B L D-1038
06/12/2019
Departmental
Use ONLY
Do NOT Mark
[Staff: Apply label
here]
PROJECT INFORMATION (This section must be filled out completely)
Scope of Work: Replace (9) antennas & (2) equipment cabinets w/ new models Valuation: $ 25,000
Occupancy: unmanned Type of Construction:
Structure Info: -Conditioned Area WA sq. ft. -Unconditioned Area N/A sq. ft. -Deck/Porch/Patio WA Si
-Retaining Wall Length N/A lin. ft. -Bedrooms WA -Bathrooms N/A -Stories N/A -Roof Height N/A
Utilities: ❑ Well ❑ Septic 0 Public Local Power Company; No potable water required
Grading: Cut N/A c.y. Fill N/A c.y. Total N/A c.y. Slope: N/A% Max Slope where Grading Occurs N/A
Area of Disturbance N/A ac. Impervious Surface Area: N/A sq. ft. (Maybe referred to Public Works for Stormwater)
WASTE MANAGEMENT - RECYCLING PLAN: (Choose one of the following)
9 A) use an Integrated Waste Management Authority (IWMA)-certified construction and demolition waste recycling facility?
❑ B) use other recycling and disposal facilities? (complete Detailed Recycling Form)
BY MY SIGNATURE BELOW, I CERTIFY TO EACH OF THE FOLLOWING:
8 1 am the property owner, contractor, or am authorized to act on the property owner's behalf, and the information I have
provided above is correct. I acknowledge that I have read and understand the information contained herein.
9 I agree to comply with all applicable county ordinances and state laws relating to building construction.
B I authorize representatives of this county to enter the above -identified property for inspection purposes.
B My construction permit application is public record and is therefore published in the weekly reports on the San Luis Obispo
County Planning and Building Department's website, as well as in the public information area. All references to names,
addresses, telephone numbers, and project information will be part of this public record. All applications must be filed under
the property owners name and address; however, I may use an alternate contact address and telephone number.
19 1 acknowledge my application will expire after 360 days (90 days for As -built permit applications), if not issued by that
time.
❑ FOR CONTRACTORS ONLY: I hereby affirm under penalty of 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 I 1
Signature of Owner/Authorized Agent
1 /20/2021
Date
Signature of Contractor Date
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1(805) 781-5600 1 TTY/TRS 7-1-1 PAGE 1 OF 2
IaR nning@co.slo.cam I www.sloplannine.ore
Construction Permit Application
BLD-1038
06/12/2019
DISCLOSURES (please initial 'yes' or'no' for each)
El Yes I have signed and completed the required Hazardous Waste and Substances Statement form (BLD-1008).
❑ Yes ® No This project requires me to obtain a D.O.S.H. Hazardous Activities Permit.
❑ Yes ® No I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Name & Address of Lender:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by
the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code: Any city or county that
requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure 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).):
❑ ],as owner of the property, or my employees with wages as their sole compensation, will do ❑ all of or i portions of the
work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves
the property, provided that the 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 it was not built or improved for the
purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State License
Law.).
❑ I am exempt from licensure under the Contractors' State License Law for the following reason:
❑ 1 have signed and completed the Owner -Builder Acknowledgment form (BLD-1006)
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 law, Section 7044 of the Business
and Professions Code, is available upon request when this application is submitted or at the following website:
httl2;//Ieainfo.leaislature.ca.gov/
Signature of Owner/Authorized Agent:
Date:
WORKERS' COMPENSATION DECLARATION
WARNING: Failure to secure workers' compensation coverage us unlawful, and shall subject an employer to criminal penalties and civil
fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest, and attorney's fees. I hereby affirm under penalty of perjury one of the following declarations:
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, issued by the Director of Industrial
Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
Policy No.
_ 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 permit is issued. My workers' compensation insurance carrier and policy number are:
Carrier: Policy Number: Expiration Date:
Name of Agent Phone Number:
_ 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, and agree that, if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
Signature of Owner/Authorized Agent/
Contractor:
Date:
NOTE: Applications will become null and void if not issued within 360 days from application (90 days for As -built permit applications),
and applicant will need to resubmit and repay fees.
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1 (805) 781-5600 1 TTY/TRS 7-1-1 PAGE 2 OF 2
planning@co.slo.ca.us I www.sloplanning.org
CoUNTYON LUIS
OSISPO
COUNTY OF SAN LUIS OBISPO BLD-1008
DEPARTMENT OF PLANNING & BUILDING 06/12/2019
Hazardous Waste and Substances Statement
Project Title: SVO0386A - 2110 Slack Street
APN(s): 073-341-0008
Per Government Code section 65962.5, known as the 'Cortese List' (AB3750), I have consulted the
following website link to determine if the subject property contains any of the listed hazardous wastes or
substances:
www.calepa.ca.gov/SiteCleanup/CorteseList
• List of Hazardous Waste and Substances sites from Department of Toxic Substances
Control (DTSC) EnviroStor database.
• List of Leaking Underground Storage Tank Sites by County and Fiscal Year from Water
Board GeoTracker database.
• List of solid waste disposal sites identified by Water Board with waste constituents above
hazardous waste levels outside the waste management unit (PDF).
• List of "active" CDO and CAO from Water Board. Please Note: This list contains many
Cease and Desist Orders and Cleanup and Abatement Orders that do NOT concern the
discharge of wastes that are hazardous materials.
• List of hazardous waste facilities subject to corrective action pursuant to Section 25187.5 of
the Health and Safety Code, identified by DTSC.
After consultation with each of the lists provided on the above website, I verify that the subject parcel(s)
and proposed development (and any alternative development sites, if applicable):
�✓ Is not included on any of the lists found on the above -referenced website.
Is included on one or more of the lists found on the above -referenced website. Pursuant to
Section 65962.5 of the Government Code, the following information is provided related to this
site/application:
Name of Applicant:
Address:
Address of Site (street name & number if available, City, State and ZIP Code):
Local Agency (city/county):
Assessor's Book, Page, and Parcel Number:
Specify any list pursuant to Section 65962.5 of the Government Code:
Regulatory Identification Number:
Date of List:
Property Owner / Authorized Agent
Name
Phone Number
Email
Amy Dresch, Jacobs Telecommunications, Inc.
# (612) 802-0452
amy.dresch@jacobs.com
Signature nmf)n-__l
Date
U9�'j1 �C��`�`\_
1/20/2021
Jacobs Telecommunications, Inc. on behalf of T-Mobile West, LLC
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1 (805) 781-5600 1 TTY/TRS 7-1-1 PAGE 1 OF 1
wwwsloplanning.ore I plan ning@co.slo.ca. us
COUNTY
`o SAN LUIS
OBISPO
COUNTY OF SAN LUIS OBISPO
DEPARTMENT OF PLANNING & BUILDING
Site Check Waiver and Checklist
Site Plan and Project Layout Checklist
North arrow
Li Exterior property boundaries / dimensions shown
L All existing and proposed structures identified,
including their proposed uses
L Dimensions for all existing and proposed
structures
BLD-1012
06/12/2019
u Distances between all existing & proposed
structures and between all structures & the
property lines
Location of all existing and proposed wells and the location of all wells within 100 feet of the property
n Location of septic tank and leach field
L:I Location of any creeks, streams, rivers, or lakes
[! Distances between well(s), septic tank, leach field and creek, streams, rivers or lakes
i, Location of proposed and existing driveways
I Location of off-street parking spaces, number of spaces, and dimensions
❑ Location of adjacent streets and alleys
11 Location of all easements (water, sewer, road, open -space, etc.)
l Path of drainage on and off the property
1 Vicinitymap- (Pleaseattach)
Site Check Waiver Request - Statement of Compliance:
I / We understand this request is to waive your department's preliminary site inspection prior to permit issuance.
The purpose of this inspection is to identify any special site specific circumstances such as drainage, expansive
soil conditions, high ground water, unstable soil, foundation or other concerns that affect the project's design or
scope of work.
I / We certify that, to the best of my/our knowledge, none of the above conditions exists on the site or, if any do
exist, the project has been designed to mitigate them.
I / We acknowledge our responsibility to complete all work in accordance with the requirements of the applicable
codes, including but not limited to the construction and land use ordinances.
I / We agree to comply with any additional requirements identified by the county building inspector during the
construction process.
I / We agree to stop work at the Building Inspector's request and obtain the services of a professional engineer or
architect, licensed in California, to design all necessary corrective measures.
Property Owner / Authorized Agent
Name
✓, Authorized Agent
Amy Dresch, Jacobs Telecommunications, Inc. on behalf of T-Mobile West, LLC
❑ Property Owner
Signature ^ _-`
Date
f_)6
�'iYl I(..�lVd`�'�-
1/20/2021
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1 805-781-5600 1 TTY/TRS 7-1-1 PAGE 1 OF 1
www.sloplanning.org lap nningCdco.slo.ca.us
COUNTY
SAN LUIS
OBISPO
COUNTY OF SAN LUIS OBISPO
DEPARTMENT OF PLANNING & BUILDING
Consent of Property Owner
BLD-1005
06/12/2019
I (we) the undersigned owner of record of the fee interest in the parcel of land located at
(address): 2100 slack Street, San Luis Obispo, CA 93405
Assessor Parcel Number 073-341-0008
identified as
for which a construction permit, land use permit,
land division, general plan or ordinance amendment, or LAFCo application referral is being filed
with the county requesting approval for: Construction Pen -nit
(specify type of project, e.g., addition to a single family residence; general plan amendment), do
hereby certify that:
Such application may be filed and processed with my (our) full consent, and that I (we) have
authorized the agent named below to act as my (our) agent in all contacts with the county and to
sign for all necessary permit applications in connection with this matter. Permits shall be issued to a
licensed contractor or an Owner/Builder Acknowledgment form (BLD-1006) will be completed
prior to permit issuance.
2. 1(we) hereby grant consent to the County of San Luis Obispo, its officers, agents, employees,
independent contractors, consultants, sub -consultants and their officers, agents, and employees to
enter the property identified above to conduct any and all surveys and inspections that are
considered appropriate by the inspecting person or entity to process this application. This consent
also extends to governmental entities other than the county, their officers, agencies, employees,
independent contractors, consultants, sub -consultants, and their officers agents or employees if the
other governmental entities are providing review, inspections and surveys to assist the county in
processing this application. This consent will expire upon completion of the project.
3. If prior notice is required for an entry to surveyor inspect the property. Please contact:
Name Scott D. or Barbara Stimson
Daytime Telephone Number #
4. ](we) hereby give notice of the following concealed or unconcealed dangerous conditions on the
property (dogs, hazardous materials or specify none):
Not Applicable
BEFORE A BUILDING PERMIT APPLICATION CAN BE ACCEPTED,
THIS FORM MUST BE COMPLETED AND SIGNED BY THE PROPERTY OWNER
AND RETURNED TO THE AGENCY RESPONSIBLE FOR ISSUING THE PERMIT.
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1805-781-5600 1 TTY/TRS 7-1 -1 PAGE 1OF2
www.sloplanning org 1 plaonlog@co.slo.ca.us
BLD-1005
06/12/2D19
Consent of Property Owner
Name
Person or entity granting consent:
Date
Property Owner
Name
Phone Number
Email
Scott D. and Barbara Stimson
oMailing
Address
City
Sra[e
Zip [ode
2100 Slack Street
San Luis Obispo
CA
93405
Signature of Property Own
�s ,� P --
(b6
V,Pr/ZGLt
Note: A copy of the property owner's driver license, notarization, or other acceptable verification 1t'
Is required to be presented to verify the property owner's signature. V
See Aflached for
Notary Certificate
Authorized Agent
Name
Amy Dresch, Jacobs Telecommunications, Inc.
Phone Number
# (612) 802-0452
Email
amy.dresch@jacobs.com
Mailing Address
2600 Michelson Drive, Suite 500
city
Irvine
State
CA
I Zip Code
92612
Signature of Authorized Agent �ffl
jacous I elecommunications, Inc. on behalf of T-Mobile West, LLC
BEFORE A BUILDING PERMIT APPLICATION CAN BE ACCEPTED,
THIS FORM MUST BE COMPLETED AND SIGNED BY THE PROPERTY OWNER
AND RETURNED TO THE AGENCY RESPONSIBLE FOR ISSUING THE PERMIT.
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1 805-781-5600 1 TTY/TRS 7-1-1 PAGE 2 OF 2
D1annInF@co.sIo.ca.us I www sloplanning,ore
CALIFORNIA ALL- PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California }
County of SOM kiiltI l Obi (P`4 }} �1
On bVV(A �21 before me, me An Q'D P4- MfAn3 Nt 11G
mereivilan name ame o can
personally appeared h A [ 6( 'c 0+1 s ' vn jo i.-�
who pro ed to me on the basis of satisfactory evidence to be the personA whose
me(xsubscribed to the within instrument and acknowledged to me that
heltbey executed the same it 11 eir authorize capacity(iio, and that by
I it signatyyrexon the instrument the person or the entity upon behalf of
which the person(;) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.
•?yam MEGAN O'DNNER
WITNESS my hand and official seal. H ' Commies on a2a22/ae
Notary Public - California ST„
i San Luis Obispo County
3f MyComm. Expaea Mareh 11. 2024oh�
3
Notary Public Si ature r (Notary Public Seal) {
OPTIONAL
DESCRIPTION OF THE ATTACHED DOCUMENT
Ny,i� 0p pi"V'�t
(Title orrr/Mof
dd�essccrriptionnof`attached document)
(Title or description of attached document continued)
Number of Pages -�L Document Date2 i �pl
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attomey-in-Fact
❑ Trustee(s)
❑ Other
2015 Version www.idotaryCla-,ses.com 800-873-9885
INSTRUCTIONS FOR COMPLETING THIS FORM
i This form complies with current California statutes regarding notary wording and.
if needed, should be completed and attached to the document. Aclm ,,kaigments
from other states may be completed jar documents being sent to that state so long
as the wording does not require the California notary to violate California notary
lame.
• State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signer(s) who personally appear at the time of
notarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/dwa -is /are) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.
Impression most not cover text or lines. If seal impression smudges, re -seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public mast match the signature on file with the office of
the county clerk.
4 Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
•: Indicate title or type of attached document, number of pages and date.
Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
• Securely attach this document to the signed document with a staple.
k
NTYAN LUIS
OBISPO
COUNTY OF SAN LUIS OBISPO
DEPARTMENT OF PLANNING & BUILDING
Landscape Information Form
Property Information
Assessor Parcel Number(s): 073-341-0008
Address: 2100 Slack Street, San Luis Obispo, CA 93405
Contact For Landscape Information
Name: Sean O'Sullivan, P.E., Jacobs Telecommunications, Inc.
Lot Size: 18.67 acres
Mailing Address: 2600 Michelson Drive, Suite 500, Irvine, CA 92612
Email: sean.osullivan2@jacobs.com Phone: # (949) 244-7604
Project
Project Type: ❑ new dwelling ❑ commercial ❑ rehab a Other wireless Telecom
0 Currently this project does not include landscaping. I am aware that future
landscape installations may be required to comply with the Model Water Efficient
Landscape Ordinance (MWELO) requirements per California Code of Regulations,
Title 23, Division 2, Chapter 2.7.
LNG-1010
06/12/2019
Departmental
Use Only
Do Not Mark
❑ This project does incorporate landscaping. (Please provide the information below specific to
the landscape area which will be completed as part of the project and specify the compliance
method to be used).
Project Information
Total Landscape Area (sq. ft.):
Non -Turf Area (sq. ft.):
Turf Area (sq. ft.):
Special Landscape Area (edible plants or areas irrigated with recycled water (sq. ft.):
Water Type: ❑ Potable ❑ Recycled ❑ Well
Name of Water Purveyor (if not served by private well):
Compliance Method
❑ Performance (Items included in Performance Checklist is included on plans)
❑ Prescriptive (Items included in Prescriptive Checklist is included on plans)
❑ Exempt Under 500 sq. ft.
By My Signature Below, I Certify to Each of the Following:
® 1 am the property owner, contractor, or am authorized to act on the property owner's behalf,
and the information I have provided above is correct. I acknowledge that I have read and
understand the information contained herein.
4mtf`lnQcl\1
Signature of Owner /Authorized Agent
1/20/2021
Date
976 0SOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1(805) 781-5600 I TTY/TRS 7-1-1 PAGE 1 OF 1
Ike@coslo.ca.us I www.sloplannine.ore
COUNTY
`o SAN LUIS
OBISPO
Instructions for Owner
COUNTY OF SAN LUIS OBISPO BLD-1042
DEPARTMENT OF PLANNING & BUILDING 04/13/2020
Registered Design Professional Permission to Process
via Citizen Self Service Portal (CSS)
The OWNER of the submitted project must complete the following information to designate the
licensed architect or engineer who is the "Registered Designed Professional in Responsible
Charge" for the project in accordance with the 2019 California Building Code.
The registered design professional in responsible charge shall be responsible for reviewing and
coordinating submittal documents prepared by others, including phased and deferred submittal
items, for compatibility with the design of the building. CBC 107.3.4
The DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE of the submitted project must
complete the following information to designate and allow the owner and agent to have access,
use the plans and supporting documents for electronic plan permit processing and printing via
Citizen Self Service Portal.
The purpose form is to grant access to the submitted copyright protected documents prepared
by various design professionals to the contacts contained in the permit.
As the OWNER OF RECORD, I designate the following person as my registered design
Professional (RDP) for the project noted. I understand that the architect/engineer designated
shall be responsible for reviewing and coordinating all submittal documents prepared by others
for the duration of the project. I also authorize the agent listed below to duplicate and use any
stamped plans during the execution of this permit. I also understand that I must provide written
notification to the County of San Luis Obispo Building Division if my designee is changed.
Please Print PMT_ 202_- 0_ _ _ _,
Project Address: 2100 Slack Street, San Luis Obispo, CA 93405
Project/Tenant Name: SVO0386A / T-Mobile West, LLC
Registered Design Professional Name: Sean O'Sullivan, P.E.
Architectural/Engineering Firm Name: Jacobs Telecommunications, Inc.
Telephone Number: (949) 501-8705
E-mail Address: sean.osullivan2@jacobs.com
Architect/Engineer's Signature Date 0142- / Lzr
Owner's Name: Scott D. and Barbara Stimson w
Telephone Number: #
E-mail Address: None f f
Owner's Signature: Date o2/O S Z�Z 1
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1 (805) 781-5600 1 TTYrrRS 7-1-1 PAGE 1 OF 2
www.sloplannine ore I planning@co.sl%ca.us
BLD-1042
04/13/2020
Information Disclosure
As the DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE, I give permission to the
following person, as the AGENT for the permit noted above, to reproduce and use any plans I
have stamped as approved during the execution of the permit. I also understand that I must
provide written notification to the County of San Luis Obispo Building Division if my designee is
changed.
Agent's Name: Amy Dresch, Jacobs Telecommunications, Inc.
Telephone Number. # (612) 802-0452
E-mail Address: amy.dresch@jacobs.com
Agent's Signature:
Registered Design Professional Name: Sean O'Sullivan, P.E.
Architectural/Engineering Firm Name: Jacobs Telecommunications, Inc.
Date 1/25/2021
Telephone Number: (949)501-8705
E-mail Address: sean.osullivan2@jacobs.com
Architect/Engineer'sSignature Date Dr�ZS/ivai
976 OSOS STREET, ROOM 300 1 SAN LUIS OBISPO, CA 93408 1 (805) 781-5600 1 TTY/TRS 7-1-1 PAGE 2 OF 2
planningcin co slo ca us i wwwsloolannine ore
CALIFORNIA ALL- PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California
County of V ah W{I f Obi rD o }
On bYUGt 144 before me, !M eqU vlO b IMF t
,1 �• �.an •
personally appeared Doj 6 l tT ++ ' '-hvnf 0+--'
who proved to me on the basis of satisfactory evidence to be the person�4 whose
name(&alw-subscribed to the wi hin instrument and acknowledged to me that
h s#te/they executed the same i h' /HeNtt-air authorizep capacity), and that by
fhll/4edttteir signat re�) on the instrument the person or the entity upon behalf of
Which the persol�(;� acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.
ME AN ie
O'DNNER
WITNESS my hand and official seal. Ca8'y ion ill r24"
Notary Public-Celifomia v
i San luia Oblspo County
MY Comm. Expirsa Match 11, 2024
Notary Public Sig nat a (Notary Public Seal)
(Title
Je1;&ILei `rG1III
OF THE ATTACHED DOCUMENT
of Pages 2 Document Date 1) Z 01 �vl
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
2015 Version www.NotaryClasses.com 800-873-9865
INSTRUCTIONS FOR COMPLETING THIS FORM
DN This form complies with current California statutes regarding notary wording and,
if needed, should be completed andattached to the document. Acknowledgments
from other states may be completed for documents being sent to that stare so long
as the wording does not require the California notary to violate California notary
/my.
• State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signer(s) who personally appear at the time of
notarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/sheldiay, is /are) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re -seat if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office of
the county clerk,
Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
Indicate title or type of attached document, number of pages and date.
Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i,e. CEO, CFO, Secretary).
• Securely attach this document to the signed document with a staple.
T • •Mobile•
July 23, 2020
T-Mobile West LLC
2008 McGaw Ave.
Irvine, CA 92614
To Whom it may Concern,
Jacobs Telecommunications Inc., it's employees and agents are authorized representatives of T-Mobile
West LLC, have been contracted to perform land -use entitlements and associated negotiations services
for T-Mobile telecommunications facilities.
As an authorized representative of T-Mobile, Jacobs Telecommunications Inc. may sign, submit, review
land -use applications and permits, represent T-Mobile at meetings and hearings, accept conditions of
approval, and negotiate lease agreements on T-Mobile behalf. All final land -use documents are subject
to T-Mobile's review and approval. Further, all leases are contingent upon T-Mobile's signature.
Please do not hesitate to contact us with any questions or comments.
Sincerely,
Jackie Le
Site Development Manager