HomeMy WebLinkAboutDraft Property Declaration Form.pdfJNSY Of H,,w1
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A1II�4iClunN of �Pa(llal 1,DEPARTMENT OF PUBLIC WORKS
PROPERTY OWNER DECLARATION FORM
MS FIRUC FIINS
COMPLETE THE SECTIONS BELOW. AN EMAIL ADDRESS IS REQUIRED FOR ALL CONTACTS —ALL
COMMUNICATION REGARDING YOUR APPLICATION WILL BE EMAILED.
LO C T IO N II N F CS IR T I1 � lIII_�1�.._�_�_�:�... F.a.._ E R.11: Y...II..Q..CAT!_O rv..i_N_FO R I.01N. )
PARCEL NUMBER
LOCATION ADDRESS
IP IR O IP E IRTY OWNER IINIFORMAF110N (Q riser contacunLormation is reuir ed)
I...IICK IINERIf: 'TO VERIFY PROPERTY O` IN E�IRSII..NII_I
.......................................................................................................................................................................
IF PROPERTY OWNIE.R(S) NAMED BEI OW I[)OF..S/[)O NOT MATCH Tl --NE COUNTY'S REAL.. If)R0PIERTY TAX
OFFICE RECORD, PI EASE SUBMIT A COPY OF THE CURRENT OWNER'S PROOF OF OWNERSHIP.
OWNER NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL
OWNER NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL
OWNER NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL
LESSEE/TENANT INFORMA F110N
LESSEE/TENANT NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL
LESSEE/TENANT NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL
Hawai'i County is an equal opportunity provider and employer
AGENT NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL
AGENT NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL
I hereby certify that I am the primary owner of the property listed above and all information provided is
accurate and complete. I understand that all contacts listed above will receive communication regarding
my permit application and plans.
PROPERTY OWNER (PRINT)
PROPERTY OWNER (SIGNATURE)
CHECK HERE IF
PROPERTY OWNER
INFORMATION ABOVE
MATCHES RPrS DATA. If
no, proof of ownership is
required.
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PROPERTY OWNFRSFIIP
Date
Hawai'i County is an equal opportunity provider and employer