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Home My WebLink AboutPRR20092 Pallamary - Engineer Notice of Department Designationp13[.SPfj COUNTY QIt� SAN LUIS OBISPO *{t #RI RECEIVED RECEIVED ibhlMl' 6Cllef�tip �; ��Ii�a4RflER MAY 0 7 2020 MAY - 12020 TY ISPO CLE - CORDER PUBLIC RECORDS ACT REQUEST FORM This form is not required to submit a California Public Records Act (CPRA) request; however, this assists staff in identifying records or data you are requesting and track your request. Please complete the form below. If the Clerk -Recorder's Office does not maintain your requested records, this form will be forwarded to the correct department, to the extent known. Name: Organization (if applicable): Michael Pallama N/A Mailing Address: Contact Phone Number: Fax Number: 7755 Fay Avenue, Suite J 858-454-4094 858-454-4667 _ City: State: Zip Code: _ Email Address: f San Diego CA 92037 1 mpallamary@pipeline.com Requested records (where applicable, include a contract or RFP number, APN, and/or property address): I would like a copy of the city's "Notice of Department Designation" form as required under state law. I have attached a blank form, to assure that you send the correct form. Applicable time frame for requested records: How do you want to receive the requested documents? From: 2010 ❑ Paper Copy (via US mail) ❑ Paper Copy (via pick-up) ❑ Electronic Copy (via fax) N Electronic Copy (via email) To: Present Note: Certified documents are only available as paper documents. Per the California Publi Records Act (CPRA), I hereby request reproduction of the following records maintained by this department and tad t there may be fees incurred in the reproduction of the records. Signatur Date: April 28, 2020 � � w Public Re r Act requests ajbe ubmitted: • Via US Mail: Mail completed form to 1055 Monterey Street, Suite D120, San Luis Obispo, CA 93408 • Via Fax: Fax completed form to (805) 781-111 1 In Person: Submit completed form to front counter staff. A response will be sent to you within (10) ten business days of receipt of your request by the Clerk -Recorder's Office. In some instances, the Clerk -Recorder's Office may require up to an additional (14) fourteen days to respond as authorized by the Public Records Act. All payments are due at the time record reproduction is provided. Questions? Please contact us: (805) 781-5080 Note: The California Public Records Act (Gov't Code Section 6250 et, seq.) applies to writings in County files "containing information relating to the conduct of the public's business prepared, owned, used, or retained by any state or local agency regardless of physical form or characteristics." The County will provide those documents to you, unless they are exempt from disclosure under the Public Records Act or other legal reason prevents the documents from being disclosed to the public. County of San Luis Obispo Clerk -Recorder 1055 Monterey Street, Suite D'120 1 San Luis Obispo, CA 93408 (P) 805-781-5080 1 (F) 805-781-1111 1 www.slovote.com STATE C OF CALIFOWA GOVERNOR EDMUND G. BROWN JR rr-''Uy BOARD FOR PROFESSIONAL ENGINEERS, LAND SURVEYORS, AND GEOLOGISTS 2535 Capitol Oaks Drive, Suite 300, Sacramento, California, 95833-2944 g °• Telephone: (916) 263-2222 - Toll Free: 1-866-780-5370 Facsimile: (916) 263-2246 ., tL ��+• www.bpelsg.ca.gov NOTICE OF DEPARTMENT DESIGNATION For California State, City, County, City/County, District, or Special District Departments (Pursuant to Sections 67302 and 8725-1 of the California Business and Professions Code, an appropriately -licensed person needs to be designated as the individual in responsible charge of land surveying and each branch of engineering services being practiced) Note: Each department that practices engineering or surveying on an independent basis must designate appropriately -licensed individuals in responsible charge of those services. List the lowest level department that has independent authority to make final engineering or land surveying decisions without having to obtain approval of those decisions by a higher level of authority. ■ State I QCity j QCounty Q City/County T District I 0—Special District Department Name Address (including city, state, and ZIP code) Telephone Number Website Address Professional Services Practiced: ❑ Civil (Structural and Geotechnical) Engineering ❑ Electrical Engineering ❑ Mechanical Engineering ❑ Land Surveying List the name, title, and license number of the licensee or licensees in responsible charge of professional engineering or land surveying services at this Department/Agency's office along with their title and license number. An Organization Chart should be attached. List individuals contracted to serve in an official capacity (i.e., city engineer, etc.). (Attach additional pages if needed) Name Title License Number Name of Person Completing this Form Signature 'title Contact Information Date Revised 9/2015 Additional Offices For California State, City, County, City/County, District, or Special District Departments (Pursuant to Sections 67302 and 8725.1 of the California Business and Professions Code, an appropriately -licensed person needs to be designated as the individual in responsible charge of land surveying and each branch of engineering services being practiced) ■) State 10 city Count r) City/County District I OSpecial District Department Name Address (including city, state, and ZIP code) Telephone Number Website Address Professional Services Practiced: ❑ Civil (Structural and Geotechnical) Engineering ❑ Electrical Engineering ❑ Mechanical Engineering ❑ Land Surveying List the name, title, and license number of the licensee or licensees in responsible charge of professional engineering or land surveying services at this Department/Agency's office along with their title and license number. An Organization Chart should be attached. List individuals contracted to serve in an official capacity (i.e., city engineer, etc.). (Attach additional pages if needed) Name Title License Number Name of Person Completing this Form Signature Title Contact Information Date Department Name Address (including city, state, and ZIP code) Telephone Number Website Address Professional Services Provided: ❑ Civil (Structural and Geotechnical) Engineering ❑ Electrical Engineering ❑ Mechanical Engineering ❑ Land Surveying List the name, title, and license number of the licensee or licensees in responsible charge of professional engineering or land surveying services at this Department/Agency's office along with their title and license number. An Organization Chart should be attached. List individuals contracted to serve in an official capacity (i.e., city engineer, etc.). (Attach additional pages if needed) Name Title License Number Name of Person Completing this Form Signature Title Contact information Date Revised 9/2015