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DocuSign Envelope ID: F55631D9-FA08-40A1-82DC-DA513FACF3B0 <br />Ornnf <br />DEPARTMENT OF PUBLIC WORKS <br />ADDITIONAL CONTACT INFORMATION (LIMIT2) <br />NAME <br />MAILING ADDRESS <br />PHONE NUMBER <br />EMAIL <br />NAME <br />MAILING ADDRESS <br />PHONE NUMBER <br />EMAIL <br />Pursuant to Hawaii County Code, Section 5-4-1(a)(7), and by my signature below, I certify the following: (1) I am <br />the owner of the property described above or the owner's authorized agent and I consent to the submittal of <br />this permit application; (2) the information in this application is accurate and complete; and (3) I understand that <br />all contacts listed above will receive communication regarding the permit application and plans. <br />Sofai Bertaina <br />Waikoloa Lutheran Church President <br />PRINT NAME <br />(—DocuSigned by: <br />s€Fai1U1L <br />`—C625c653A85248B... SIGNATURE <br />CHECK THE BOX IF <br />PROPERTY OWNER <br />INFORMATION ABOVE <br />MATCHES RPT'S DATA. <br />If no, proof of ownership is <br />required. Verify at: <br />www.hawaiipropertytax.com/ <br />search.html <br />5/1/2024 <br />Hawai'i County is an equal opportunity provider and employer <br />DATE <br />