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DocuSign Envelope ID: F55631D9-FA08-40A1-82DC-DA513FACF3B0 <br />ttiunf <br />DEPARTMENT OF PUBLIC WORKS <br />V3 4/10/2023 <br />PROPERTY OWNER DECLARATION FORM <br />INSTRUCTIONS <br />COMPLETE THE SECTIONS BELOW. AN EMAIL ADDRESS IS REQUIRED FOR ALL CONTACTS—ALL <br />COMMUNICATION REGARDING YOUR APPLICATION WILL BE EMAILED. <br />LOCATION INFORMATION <br />(VERIFY AT: www.hawaiipropertytax.com/search.html) <br />PARCEL NUMBER <br />6 - 8 - 002 - 056 <br />- 0000 <br />LOCATION ADDRESS <br />68-3670 Paniolo Avenue, Waikoloa, HI <br />96738 <br />PROPERTY OWNER INFORMATION (Owner contact information is required) <br />(VERIFY AT: www.hawaiipropertytax.com/search.html) <br />IF PROPERTY OWNER(S) NAMED BELOW DOES/DO NOT MATCH THE COUNTY'S REAL PROPERTY TAX <br />OFFICE RECORD, PLEASE SUBMIT A COPY OF THE CURRENT OWNER'S PROOF OF OWNERSHIP. <br />OWNER NAME <br />Waikoloa Lutheran Church <br />MAILING ADDRESS <br />MAILING ADDRESS <br />PO BOX 383046, Waikoloa, HI 96738 <br />3046 <br />PHONE NUMBER <br />808-345-9033 <br />EMAIL <br />erik@jacobsonteamhawaii.com <br />OWNER NAME <br />MAILING ADDRESS <br />PHONE NUMBER <br />EMAIL <br />OWNER NAME <br />MAILING ADDRESS <br />PHONE NUMBER <br />EMAIL <br />AUTHORIZED AGENT INFORMATION <br />AGENT NAME <br />Steven Sung / Agent to Horizon Tower, LLC <br />MAILING ADDRESS <br />2333 Kapiolani Blvd #3211, Honolulu, HI 96826 <br />PHONE NUMBER <br />(808) 223-0323 <br />EMAIL <br />steven.sung8@gmail.com <br />Hawai'i County is an equal opportunity provider and employer <br />