HomeMy WebLinkAbout2340 VIA FRANCISCA; ; 83-271-2-6; Permiten z 0 .: • a: • .. u ... 0
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O I h«eby aff!lm that 1•am licensed under
p,ovlalona of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business
and Professions Code, and my llcense is In
full force and effect.
lie No ______ Class
1 hereby alhrm that I am exempt from lhe Contrac· tor"s License Llw lor the following reason (Sec 7031 5
Business and Professions Code Any city or county which re· qu1tes a permit to construc1. alte<. ,mp,O'le, demolish, Of repair any slructure, prior lo ,ts issuance also requires ?heap·
phcant for such perrrut to lite a signed statement thal he is licensed pursuan1 to the provistons ot lhe Contractor" s
Uc.ense Law (Chapter 9 commencmg with Section 7000 of 0ivIs1on 3 ol the Business and Prolessions Code)°' thal 1s ex· empt lher om and !he basis tor lhe allegeO exempt10n Any
VMMa110 f Secl1on 7031.5 by an applfCanl tor a permll sub· Iects e applicant to a cIvIt pena11y of not more th.an live hun· or dollars ($500)
□ I. as owner of the properly. Of my employees with wages
as their sole compensation, wflt do lhe work. and the struc-
ture Is nol ,ntended or offered tor sale (Sec 7044, Business
and Professions Code The Con1rac1or·s License Law does not apply to an owner ol property who builds or 1mpr0Yts
thereon and who does such work h1msell or through his own empIDyees. provided that such improvements are not intend· ed or ottered tor sale U. however, the building or Improve-men1 is soki within one year of completion. the owner-builder
Z'II ha the burden of proving that II< did not build or 1m· the purpose of sale)
owner of !he property, am exclusively contractmg with licensed contractors lo construct lhe pro,ect (Sec. 70..4.
Business and ProfessNJns Code· The Contract0<'s License Law does not apply lo an owner of properly who builds or im•
proves thereon, and who contracts for each projects with a contractor(s) license pursuanl 10 the Contractor's License Llw).
0 As a homeowner I am improving my home, and the totlow-ing conditions exist
1. The work is being performed prior to sale. 2. I have lived in my home for twelve months prior to completion ot this WOfk.
3. I have not claimed this exemption during the last three years.
D 1 am exempt under Sec. ______ , B & P.C.
10< this reason ____________ _
□ I hereby affirm that I ha"e a cert1f1cate ot consent
to self-insure. or a cert1t,cate ot Workers·
Compensation Insurance. or a cert1f1ed copy tttereot
(Sec 31!()(). Labo< CodeJ
~
I NO
CO PANY
Copy IS filed With the City
0 Certified copy ,s hereby lurn,shed
CERTIFICATl OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
{This section need no1 be completed 11 lhe perm11 ,s for one hundred dollars (S 1001 o, less)
D I certify that in the performance of lhe wor1"1. to,
wh1cn this permll ,s ,ssued. I shall no1 employ any
person m any manner so as to become sub1ec1 to
the Wot1it..ers· Compensation Laws of Calilo,n,a
NOTICE TO APPLICANT II. atler makmJ 1h1s Gerti
l+cate ol Exemption. you should t>ecome sub1ec1 l'l
lhe WOf'kers· Compensahon pro"1s1ons 0·1 me Labor
Code. you must tor,h.,1th comply w11t1 such
prov1s1ons or 1fl1s permit shall be oeemed revoked
0 I hereby affirm Iha! there 1s a consouct10n 1end1ng ~ency tor the periormance ot the woni. to,
wh,ch lh1s permI1 1s issued lSec 3097. C1v1I Cadet
'-enders Name ___________ _
'----dd,ess __________ _
1 USE BALL POINT PEN ONLY & PRESS HARD APPLICANT TO FILL IN INFORMATION WITHIN SHADED AREA AND DECLARATIONS.
CARLSBAD BUILDING DEPARTMENT APPLICATION & PERMIT
1200 Elm, Carlsbad, California 92008-1989 (619) 438-5525
JOB ADDRESS
2340 Via Francisca
AV-ST.RD. NEARESTCROSSST.
Hoso l0To1,tp ~8~1 BUSINESS LICENSE It VALUATION
fJl.eJ13
ZONE "
PERMIT NUMBER
LOT BLOCK ASSESSOR PARCEL NO CONTRACTOR -, I CONTRACTORS PHONE • 83-271 -2-6 I SUBDIVISION l
OWNER·s NAME -, OWNER"S PHONE Community _Re_SOJ.Jrces Coro .
Community Resources Corp . 483-6500 CONT RA CT OR'S ADDRESS
-----
OWNER'S MAILING ADDRESS
2204 Garnet Ave., San Diego, Ca. 92109 DESIGNER
Bldg. 2-6 15 ~L4'0
DESCRIPTION OF WORK IJ-t?il#"e wt I DESIGNER'S ADDRESS I Units
1------------------
CStL ~"~-new ~~·tr
CENSUS TRACT I GP LANO USE PARKING SPACE RE\ STS l
QTY.I PLUMBING PERMIT • ISSUE
EACH FIXTURE TRAP
EACH BUILDING SEWER
EACH WATER HEATER ANO/OR VENT
EACH GAS SYSTEM 1 TO 4 OUTLETS
EACH GAS SYSTEM~ OR MORE
EACH INSTA~ .. ALTER, REPAIR WATER PIPE
EACH VACUUM BREAKER
WATER SOFTNER
EACH ROOF DRAIN (INSIDE)
TOTAL PLUMBING I
QTY.I ELECTRICAL PERMIT· ISSUE
NEW CONST EA AMPISWTIBKR
I PH 3 PH
EX 1ST BLOG EA AMP/SWT /BK R
1 PH 3 PH
REMOOEL'ALTER PER CIRCUIT
TE MP POLE 200 AMPS
OVER 200 AMPS
TEMP OCCUPANCY (30 DAYS!
TOTAL ELECTRICAL 1
FI P FLA ELEV.
vO NO
GRADING PERMIT ISSUED 1 REDEVELOPMENT
AREA
YO ND v0 Nb(._
QTY. MECHANICAL PERMIT • ISSUE
INSTALL FURN. OUCTS UP TO 100.000 BTU
OVER 100.000 BTU
BOILER/COMPRESSOR UP TO 3 HP
BOILER /COMPRESSOR 3-15 HP
MET AL FIREPLACE
VENT FAN SINGLE OUCT
MECH EXHAUST -HOOO/OUCTS
RELOCATION OF EA FURNACE/HEATER
TOT i.L MECHANICAL
QTY. I SOLAR • ISSUE
COLLECTORS
STORAGE TANKS
ROCK STORAGE
PUMP
PLAN CHECK FEE
TOTAL SOLAR
LICENSE NO.
LICENSE•
OESIGNER•S PHONE
~
ST~S
~CGP
K-\
I OCC LOAD TYPE
~)T~!I
EDU
FIRESPR
v□ N~
PLAN 1.0. # BLOG USE CODE
STANDARD PLAN # BUILDING SO. FOOTAGE
/_0;053
1-0/ l"el831'7Ji4
• ~ -..... ---751.i I'~ 7 ...
Not Valid Un~s Machine Certified
SUMMARY/ACCOUNT NUMBER ~A
BUILDING PERMIT 01 ·00·00·8220 rJ!JifJ,
SIGN PERMIT 01 ·00-00·8221 ~ -
PLAN CHECK 01 ·00-00·8806 ~~
TOTAL PLUMBING 01-00·00·8222
ELECTRICAL 01·00-00-8223
MECHANICAL 01·00·00-8224
MOBILEHOME 01 ·00-0Q-8225
MOBILEHOME PARK INSP
SOLAR QH!Q·QQ-8226
STRONG MOTION 80-92·33·0519
.,JJ111.A11 2/61 ~
FIRE SPRINi<LERS 01 ·00-00-8227 ~
PU8LIC FACILITIES FEE 32·00·00·8933 ---z:-2~~-
BRIDGE FEE
.,
SCHOOL FEE • DISTRICT
Carlsbad 80·92-21 ·0519
Encinitas 80·92·22·0519
San 0ieguito 80-92-23-0519
San Marcos 80·92-24-0519
LICENSE TAX 01-00-00-8162
CREDIT DEPOSIT
TOTAL FEES PAYABLE I 1t/J'.I
'! HAVE CAREFULLY EXAMINED THE COMPLETED '·_APPLICATION AND PERMtr' ANO DO HEREBY Ex111ralk>n E~ penntl-by1M8ulldtng0ff1Ctalunde<theprov1S1on1ofth,s
CERTIFY UNDER PENALTY OF PERJURY THAT ALL INFORMATION HEREON INCLUDING THE Code II•• by limitation -become null and v01d If lhe bUllding or work
* AN OSHA PERMIT IS REQUIRED FOR bCAVATIONS OYER s· O"' DEEP ANO OEMOI..ITION OR CONSTRUCTION OJ
OECLARA TIONS ARE TRUE AND CORRECT ANO I FURTHER CERTIFY ANO AGREE IF A PERMIT tS aulh by h permit IS not commenced Wf1llin 180 days from 1"'-' dale of such
ISSUED TO COMPLY WITH ALL CITY, COUNlY AND STATE LAWS GOVERNING BUILDING CON• Li~~~~11
~~bu~•~d;d'~:,'X~or~~-~~au!IUh~or~tzad~!!!!by~ou}c~h;..i_perjm~,~• L••~•us!!lpen~dedn:_:
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ST RUCTION WHETHER SPECIFIED HEREIN OR NOT I ALSO AGREE TO SAVE INDEMNIFY AND I me a 81' !he worlt
1
• commenced for a od of
1
KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES. JUDGMENTS. COSTS AND NATURE • co ... TRACTOR O APPJO ED BY -~ ott /2
EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE ..L. f lfj
GRANTING OF THIS P6RMIT ~~ BY PHONE O ~ // R:Ji
STRUCTURES OYER 3 STOAIES IN HEIGHT
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TYPE I DATE INSPECTOR . I
I BUILDING i
FOUNDATION !
REINFORCED STEEL i
MASONRY !
I
GUNITE OR GROUT I
FLOOR & CEILING SUB FRAME I
SHEATHING D ROOF D SH~AR
FRAME I
! EXTERIOR LATH I
INSULATION i
INTERIOR LATH & DRYWALL I
' I
PLUMBING I
SEWER AND BUCO DIPUCO I
UNDERGROUND D WASTE D WATER
TOP OUT D WASTE D WATER
TUB AND SHOWER PAN I
GAS TEST :
D WATER HEATER D SOLAR WATER
I
ELECTRICAL I I
D ELECTRIC UNDERGROUND DUFFER
ROUGH ELECTRIC I •.
D ELECTRIC SERVICE D TEMPO~ARY .
D BONDING D POOL I
I
I MECHANICAL I
D DUCT & PLEM., D REF. PIPING -r· II". .... , ... 1'! ,r,. . J . HEAT -AIR COND. SYSTEMS I .
I VENTILATING SYSTEMS I
I
CALL FOR FINAL INSPECT~~N WHEN ALL APPROPRIATE ITEMS ABOVE HAV BEEN APPROVED.
FINAL I ~ /
PLUMBING .
I e:' ~~ ,..--~
ELECTRICAL I t:::QI_........ -~ 1 cr-J I
MECHANICAL l (\~ t::.---:::-n..,7 r
GAS I --i,.c...•V' ., BUILDING I
I
SPECIAL CONDITIONS ! .
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FIELD INSPECTION RECORD .
REQUIRED SPECIAL INSPECTIONS INSPECTOR'S NOTES
~
'· " REQ IF INSPECTORS INSPECTION CHECKED APPROVAL DATE '·
SOILS COMPLIANCE
PRIOR TO
FOUNDATION INSP
STRUCTURAL CONCRETE
OVER 2000 PSI
PRES TRESSED
CONCRETE
POST TENSIONED
CONCRETE
FIELD WELDING
' HIGH STRENGTH
": .... ,.r·-, .. ' BOLTS ----. ~ ""!•::.-
SPECIAL MASONRY . , <.", ,'...; .
°"\' ,,,
PILES CAISSONS
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O I hereby a HI rm that J. am licensed under
provlolono of.{'.,t,apter 9 (commencing with
Section 7000) of Division 3 of the Business
and Profeoolons Code, and my license is In
lull force and effect.
LIC No------Clm
I hereby aHirm that I am exempt lrom the Contrac· tor's Ltcense Law tor the following reason (Sec 7031 5
Business and Protess10ns Code. Any city or county whacr+ re-quires a permII 10 construct. atter. tmprove. demohsh. or
repair any structure. pnor to ,ts issuance also requires !heap-
=~~orp~~;~~r:• N:/~,~~~~: ~~r1i~~~~~~~!!
License Law (Chapter 9 commencmg wIlh Section 7000 ot
Division 3 of lhe Business and ProtesStOns Code} or that ,sex-empt therefrom and the basis fo, the alleged exemphon Any v,olat,on of Section 7031 .5 by an apphtant to, a perm,t sub·
jects the apphtant to a civil penalty of not more than five hun•
ac "' 0
gdotlars ($500).
as owner ol the p,operty. o, my employees w,th wages
eir sole compensahon, will do the WOJk. and lhe struc-ture ,s not Intended or offered for sale (Sec 7044, Business
and Professions Code. The Contracta<'s License law does ~ 5 ~ "' z
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not appty to an owner of property who builds CN' improves !hereon and who does such work himself °' through his own
employees. provided that such improvemenls are not intend· eel or offered for ~le. If, however, the building or improve-
ment is sold within one year of complet10n, the owner-builder will ii.ave the burden of proving th.al he did not build or im·
~
tor the purpose of sale).
as owner or the property, am exclusivefy e-0ntrachng
censed contracto,s to construct the prorect (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner ol property who builds or im-proves !hereon. and who contracts tor each projects with a contractOf{s) license pursuant to the Contractor's Ucense Law).
D As a homeowner I am irnprOYing my home, and the follow· ing condihons exist: 1. The wo,k is being pertormed p,ior to sale. 2. I have lived in my home tor twelve months
prior to completion of this work. 3. I ii.ave not claimed this e,emption durino the last three years.
D I am exempt under Sec. ______ . B & P.C. tor this reason ____________ _
□ I hereby athrm that I have a cer11t1cate ot consent
to self-,nsure. or a cer11t1ca1e ot Workers·
Compensahon Insurance. or a c-er11hed copy thereof
(Sec 3800. Labo< Code)
POLICY NO
ENY
y ,s hied with the city
1hed copy 1s hereby furnished
CERllFICATl OF EXEMPltON FROM WORKERS' COMPENSATION INSURANCE (Ttus section nee<:I not be completed 11 the permit
1s tor one hundred dollars (S 100) or less)
0 I certify u,,t 1n the perfor~nce ot the *o,1\ tor
•tuch this perrmt 1s issued, I shall QOI employ any
pe-rson in ¥1Y manner so as 10 t>ecome sut>1ect 10
lhe Wol"l\e1s· Compensation Laws o l Cahlorn1a
NOTtCE TO APPLICANT If. after makm1 this Cert•
ltcate ot b:emphon. you snouk1 become sut>1ec1 I'>
the Wor1'..ers· Compenytion p,ov1sK>Os ol the l..abof
Code. you musl lorth....-1th comply Wllh .such
p,ov1s1ons or 1t11s petm11 shall be dee-med revo«ea
0 I hereby affirm ln.11 there 1s a construchon
lend.no ~ency IOf the penormance 01 lhe work tor
which H'us permit 1s issued tSec :m1 Civil Cooe1
Lenders Name ___________ _
Lender's Address __________ _
USE BALL POINT PEN ONLY & PRE~ _HARD APPLICANT TO FILL IN IN FORMATION WITHIN SHADED AREA AND DECLARATIONS.
~ ~
CARLSBAD BUILDING DEPARTMENT
1200 Elm, Carlsbad. California 92008-1989 (619) 438-5525
APPLICATION & PERMIT
J08 ADDRESS AV. ST.RO. NEAREST CROSS ST.
'
DATE OF APPLICATIONII BUSINESS LICENSE It VALUATION PERMIT NUMBER
2340 Via Francisca Hoso 9/21/83 ~~ D 1,,.,.~
LOl BLOCK I sueo,vIsroN I ASSESSOR PARCEL NO. CONTRACTOR CONTRACTORS PHONE • ZONE i "J "I'
OWNER'S NAME I OWNffl'S PHONE 0 ~--,mitv R,:,,::,nurcei:: Corn.
Community Resources Corporation 483-6800 CONTRACTOR'S ADDRESS LICENSE NO. PLAN 1.0. # BLOG USE CODE
OWNER'S MAILING ADDRESS
DESIGNER LICENSE# STANDAFlO PLAN# BUILDING SO. FOOTAGE
2204 Garnet Avenue, San Diego, Ca. 92109
DESCRIPTION OF WORK
-DESIGNER'S ADDRESS DESIGNER'S PHONE ~~t' Q~-H .• ~i., 2i725',2't
-Building 2 6 15 Uniis F/P FLR ELEV. NO OCC GP EDU STORIES
FOUNDATION ONLY vO NO
CENSUS TRACT I GP LANO USE I PARKING SPACE I RES UNITS I GRADING PERMIT ISSUED I REDEVELOPMENT TYPE OCC LOAD FIRE SPR ARE A CONST
y □ N D vO NO vO NO Nor Valid Unl~s Machine Ctrtififtf
QTY. PLUMBING PERMIT • ISSUE "7.(!:_. QTY. MECHANIC AL PERMIT· ISSUE 3 -SUMMARY/ACCOUNT NUMBER 1/_ __.....,..
EACH FIXTURE TRAP INSTALL FURN. DUCTS UP TO 100.000 BTU BUILDING PERMIT 01 ·00·00·8220 7;:J,") ·-
EACH BUI LO ING SEWER OVER 100,000 BTU SIGN PERMIT 01·00·00·8221 -
EACH WATER HEATER ANO/OR VENT BOILER/COMPRESSOR UP TO 3 HP PLAN CHECK 01 ·00·00·8806 :.t11i¥~
V'
EACH GAS SYSTEM l TO 4 OUT LETS BOILER/COMPRESSOR 3-15 HP TOTAL PLUMBING 01 ·00·00·8222
EACH GAS SYSTEM 5 0 R MO RE METAL FIREPLACE ELECTRICAL 01 ·00·00·8223
EACH INSTAl . ALTER. REPAIR WATER PIPE VENT FAN SINGLE DUCT MECHANICAL 01 ·00·00·8224
EACH VACUUM BREAKER MECH EXHAUST -HOOOIOUCTS MOBILEHOME 01 ·00·0Q·8225
WATE R SOFTNER RELOCATfON OF EA FURNACE/HEATER MOBILEHOME PARK INSP
EACH ROOF DRAIN (INSIDE) SOLAR n1.m-nn.aooc -;'/I']~
TOTJ..L MECHANICAL STRONG MOTION 80·92·33·0519 t' -
TOTAL PLUMBING I FIRE SPRINKLERS 01 ·00·00-8227 A
s=-QTY. SOLAR -ISSUE
PUBLIC FACILITIES FEE 32·00·00·8933 7lYU-
QTY. ELECTRICAL PERMIT • ISSUE BRIDGE FEE
NEW CONST EA AMP/SWT 18KR COLLECTORS SCHOOL FEE -DISTRICT
I PH 3 PH STORAGE TANKS Carlsbad 80·92·21·0519
EXIST BLOG EA AMP/SWT/SKR ROCK STORAGE Encinitas 80·92·22·0519
1 PH 3 PH PUMP San Oieguito 80·92· 23·0519
REMOOEL'ALHR PER CIRCUIT PLAN CHECK FEE San Marcos 80·92· 24-0519
TEMP POLE 200 AMPS
0 VER 200 AMPS LICENSE TAX 01-00-00-8162 /
TEMP OCCUPANCY (30 DAYSI /11~L.)
CREDIT DEPOSIT ,(JI~
TOTAL ElEClRICAL l TOTAL SOLAR TOTAL FEES PAYABLE I 27),~;!:!
'tHAVECAREFULLYEXAMINEDTHECOMPLET~·•A~·: =1:.:·._ ._ • rr-·p;=l'lElr/; 0 E,ipiraMOn.£wryper111itlMued~""8ullciftoCllicletundlrt11ep,ov111ansof-
, * AN OIIHA flEfNff IS IIEQUMED FOR EXCAVAllONS OVEl'I . · •• · • · • -·· · •· ODde.,,.. .. _IIV ____.._.YUW.ff1t1e==,.;c,,wor1i !I' 0-OEEP ANO OEMOUT10N OIi (lQNSTRUCTION Of' CERTIFY UNDER PEl'µLtY ~ PENURY THAT AU .. THE •lllorlzedlly9UCll~il ··Wllhili1110c111ptromllle olsucll
DECLARl,TIONS ARE '\'RUE ANO COMRECT ANO I~ Cl!RTif'li~~ PIIIMIT IS ,..,..,11, or If Ille • 6w ~ _..., by SUC11 permtt 19 or STIIIClUIES.~ 3 STORIES IN HEIGHT
ISSUED 10 COMPLY WITH ALLCFTY. COUNlY AND~TEa...-OINGCON-•--•• _... fora-o1 11111~ -
STRUCTION. WHETHER SPECIFIE. D HEREIN OR NOT. I.Al.SO ~-;f6_. SAVE INDEMNIFY AND APPLICANTANT~,;;J-, OWNER□ CONTRACTOR 0 APPR VEDBY < . -:~/~ KEEP HARMLESS n tE CITY OF CARLS8AD AGAINST ALL LIAlll~ITll!.Si,IUOCJlirlJl!fT 00STS ANO
EXPENSES WHICH MAY IN ANY·W.Y"'ACCRUE AGAINSI' SAID CITY ~ OF THE 8Y PHONE 0 ~--... ~ . GRANTING Of THIS PERMIT. . , _,, • ~ --, ~,,
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TYPE I DATE INSPECTOR I '
BUILDING I /_
r\. 'll'L.---
''-. -,, f i3 -';}-7 ,-~ ~d ' --. • . ...
FOUNDATION I ' 0'1/l (.L~ ~ FIELD INSPECTION RECORD \ ·,
REINFORCED STEEL I t' /v,u.,., ~ ~-
MASONRY I
-. '
REQUIRED SPECIAL INSPECTIONS INSPECTOR'S NOTES
GUNITE OR GROUT I
FLOOR & CEILING SUB FRAME I
I
SHEATHING D ROOF D SHEAR
FRAME I '
~ -.> -.-• INSPECTION REO IF INSPECTOR S DATE ' :. -CHECKED APPR OVAL -., / -. -✓ SOILS COMPLIANCE I J.-'· PRIOR TO -.. ' \ FOUNDATION INSP ' ~
EXTERIOR LATH I \ I
INSULATION ! \
INTERIOR LATH & DRYWALL I ' /
I l, ?_,~xr' ~,,r_ -AJ
STRUCTURAL CONCRETE I OVER 2000 PSI '· I
PRESTRESSED I -,
CONCRETE ,
POST TENSIONED ll
CONCRETE
., PLUMBING I ' / FIELD WELDING
SEWER AND BUCO DIPUCO I ... ~r,1Q2 ~
UNDERGROUND D WASTE D 'rJATEfY t V \ """"' c:::-,~
TOP OUT D WASTE D WATER n.,Z/1~ ~ ~~
HIGH STRENGTH ~ ··:s:;\\--BOLTS -I . SPECIAL MASONRY t ' I
TUB AND SHOWER PAN I ~-?,~ I / l'C~J \C
GAS TEST I IV ... --
PILES CAISSONS -D WATER HEATER D SOLAR WATER
I
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ELECTRICAL I
D ELECTRIC UNDERGROUND D UFFER
ROUGH ELECTRIC I
I
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D ELECTRIC SERVICE D TEMPOJ=IARY ·,•
~~..., ... ,.. -... 4 -
D BONDING D POOL I ' ~' --' :---~ -' -I
I -. . -
MECHANICAL I ' .. , ..
D DUCT & PLEM., D REF. PIPING ~ -' ,.
HEAT -AIR COND. SYSTEMS I
I
VEN.TILATING SYSTEMS I
I
I --CALL FOR FINAL INSPECT~rN WHEN ALL APPROPRIATE ITEMS ABOVE HAV BEEN APPROVED.
l_.:" -.. !. ~ ::.. -•· •
FINAL I \
PLUMBING I , . JV
ELECTRICAL I 'l!:_~1 /j I I
MECHANICAL I I l Dlf"' ,I Y" I I
GAS I .JI I' ~ I-{' V ,/1
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BUILDING I # IV' I ''-' ---: .
SPECIAL COJ'IDITIO~S I rr -
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O I hereby affirm IJ;iat I am licensed under
provisions of Chapter 9 (commencing with
Section 7otlo) of Division 3 of the Business
and Professions Coda, and my license Is In
lull force and effect.
Lie No ______ Cliass
I hereby afhrm thal I am exempt lrom lhe Contrac· tor's License Law tor the following reason (Sec 7031 5
Business and Pro!essions Code Any city or county whteh re-quites a permit to cons1ruct. alter ,mprove. demolish, °' repair any struclure. poor to !Is issuance a1s0 requires !heap· phcanl for such permit to lue a s,9ned sta1ement lhat he ,s
hcensed pursuant lo the provisions of the Conlractor s
license Law (Chapter 9 commeneinq wIlh Section 7000 ol ON1sion 3 of lhe Busmess and Pr01es.st00s Code, or that ,sex·
empl therefrom and lhe bas,s for the allegea exemption Any v1ota.hon of Secuon 7031.~ by an app\tcant for a perm,1 sub· iects the apphcanl to a civ~ penalty of not more lhan hve hun·
dred dollars ($500)
D I. as owner ol lhe property. Of my employees with wages
as their sote compensa110n. w11l Clo the work. and the struc-ture Is not intended or otferect tor sate {Sec 7044 Business
and Proless1ons Code. The Conlrac1or's License law does
nol apply to an owner ol property who builds or improves
thereon an<I who does such WOfk himself or th10ugh his own employees. provided lhat such 1mprovements are not intend-ed or ollered tor sale 11, however, the building or ,mprove-
menl 1s sokl w1lhin one year 01 comptetlOll. lhe owner-builder
wII. have !he burden of prov,ng that he did not build or im-prove for the purpose ot sale).
D I. as owner Qf the property. am exclusrve.ty contracting with licensed conlractors 10 construct lhe pr01ect (Sec 7044,
Business and Protess1ons Code: The Contractor's Ucense uw does not apply to an owner of propeny wno buikls or im-proves thereon, and who contracts lor each pro,ec1s with a
contractor{s) license pursuant to the Contractor's L.cense Law)
□ As a nomeowner I am 1mprov,ng rrr, home, and the follow·
ing condI1tons exist 1. The work Is being performed pnor 10 sale
2. I have hved in my home for twelve months prior to compleltan of lhlS work. 3. I have not claimed this exemption during the
last lhree years
□ I am exempt under Sec. ______ . B & P.C.
tor this reason ____________ _
0 I Mreby alfum tt'lat I ha·.,e a cen11tcate ot consen1
to self-insure. or a cert,t,cate ot Workers
Compensa11on Insurance. Of' a cert1he<i copy thereof
(Sec 3800. Labo< Code)
POLICY NO
COMPANY
□ Copy IS filed with lhe city
0 Cen1hed copy 1s hereby furnished
CEATIFICATl OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(Hus section neeo not be comple1eo 11 lhe perm,t 1s tor one hundred dollars tS 1()()) or less)
O I cert1ly that in the pertormance of the wor,i; !or
wh1ct1 this pemul 1s issued. I shall not employ any person ,n any manner so as 10 become sub1ec1 10
the Workers Compensation Laws ot Cahtom,a
NOTICE TO APPLICANT It alter mak1n1 this Cert1
t,cate of Exemp11on. you sflould become sub1ect 1,:,
the Wor1'1.ers· Compensa1t0n prov,s,ons ot lhe Labor
C()()e. you musl tonh~1th comply w,1n such
prov,s1ons o, 1n1s perm1, shall De deemed ,e-wokeo
0 I flereby ath,m that !here ,s a con!lfuc11on
lending .agency tor the performance ot lhe wo""-tor
wn1ch this oerm11 ,s ,ssued !Sec '!J:/37 Crv1I CooeI
Lenoer s Name ___________ _
Lender's Address ___ r~--------
USE BALL POINT PEN ONLY & PRESS HARD APPLICANT TO FILL IN INFORMATION WITHIN SHADED AREA AND DECLARATIONS.
CARLSBAD BUILDING DEPARTMENT APPLICATION & PERMIT 1200 Elm, Carlsbad, California 92008-1989 (619) 438-5525
JOB ADDRESS Alf.ST.RO. NEARESTCAOSSST DATE OF APPLICATION BUSINESS LICENSE• VALUATION PERMIT NUMBER
~,.P~ _,--::~ ll~ /0,2,/J>-!>
SUB01 VISION ASSESSOR PARCEL NO CONTRACTOR CONTRACTORS PHONE• ZONE 2 j • )._, /-:l \
OWNER'S NAME I/) OWNER'S PHONE r
~31/0
LOT BLOCK
~~~'(;.~~~~i~~~~~~~~~-~~~~-.li~~j'/,~i~3~. :_-~~~~-!:0~2_J :~o•;;,s ~ E~ PLAN 1.0. # BLOG USE CODE
_J~'] 1/,() -~ ~AL~-.. _J DESIGNER LICENSE" STANDARD PLAN# BUILDING SO. FOOTAGE
DESCRIPTION OF WORI< c7
>-~ # c::J./
CENSUS TRACT I GP LANO USE -l PARKING SPACE
DESIGNER'S ADDRESS
/S~
RES UNITS I GRADING PERMIT ISSUED
y D ND
F/P FLA ELEV.
vO NO
1 REDEVELOPMENT
AREA
vO NO
NO
STORIES
TYPE
CONST
DESIGNER'S Pt-!ONE
DCC GP EDU
CCC LOAD I FIRE SPA
vO NO !!f!.._ "(alfd Un/,tss M•chine Cerrifi«I
-t.-! ~
QTY. PLUMBING PERMIT · ISSUE 2.5a QTY.I MECHANICAL PERMIT· ISSUE 3,.(J,, SUMMARY/ACCOUNT NUMBER
,/41 EACH FIXTURE TRAP d.lt>_. -INSTALL FURN. DUCTS UP TD 100,000 BTU BUILDING PERMIT 01·00·00·8220
LI EACH BUILDING SEWER t,.sz:, DVE R 100,000 BTU SIGN PERMIT 01 ·00·00·8221
/_5TE'ACH WA TEA HEATER AND/OR VENT
EACH GAS SYSTEM l TO 4 OUTLETS
37:-. t;T;. BOILER/COMPRESSOR UP TO 3 HP
BOILER/COMPRESSOR 3 15 HP
PLAN CHECK 01 ·00·00·8B06
TOTAL PLUMBING a 1-00·00-8222 I ..:2.. 7~ _.
EACH GAS SYSTEM 5 OR MORE METAL FIREPLACE ELECTRICAL 01-00-00·8223
EACH INSTAl . ALTER, REPAIR WATER PIPE VENT FAN SINGLE DUCT MECHANICAL 01 ·00-00-8224
6i'"'!ACH VACUUM BREAKER ~--.SZ MECH EXHAUST -HOOD/DUCTS MOBILEHOME 01 ·00·00·8225
WATER SOFTNER RELOCATION Of EA FURNACE/HEATER MOBILEHOME PARK INSP
EACH ROOF DRAIN ( INSIDE) SOLAR Ql ·QQ·QQ·B226 TOTI.L MECHANICAL STRONG MOTION 80·92·33-0519
TOTAL PLUMBING l dzt;/.-FIRE SPRINKLERS 01·00·00·8227
QTY. ELECTRICAL PERMIT • ISSUE ..5:tJ (} II QTY. I SOLAR. ISSUE PUBLIC FACILITIES FEE 32·00·00·8933
BRIDGE FEE
NEW CONST EA AMP 'SWT BK R COLLECTORS SCHOOL FEE • DISTRICT
l PH 3 PH STORAGE TANKS Carlsbad 80·92·21-0519
EXIST BLDG EA AMP/SWT/BKR ROCK STORAGE Encinitas 80·92·22-0519
I PH 3 PH PUMP San Dieguilo 80·92· 23·0519
REMODEL ALHR PER CIRCUIT PLAN CHECK FEE San Marcos 80·92· 24·0519
TEMP POLE 200 AMPS
OVER 200 AMPS LICENSE TAX 01-00-00-8162
TEMP OCCUPANCY 130 DAYS!
CREDIT DEPOSIT
TOTAL ELECTRICAL l TOTAL SOLAR TOTAL FEES PAYABLE I .)..Jr, -
I HAVE CAREFULLY EXAMINED THE COMPLETED "'APPLICATION AND PERMIT' AND DO HEREBY • ,ration Ell8f)' permit issued by Ille Bu1ld1r111 Off1c111 under tneprovis1ons of tn,s
CERTiFY UNDER PENALTY OF PERJURY THAT ALL INFORMATION HEREON INCLUDING THE re by itm,tallon and become null and void II the bu•ld,ng or work
* AN OSHA PEIMIT IS REQUIRED F0A EXCAVATIONS OVER
5· O" DEEP ANO DEMOLITION QA CONSTRUCTION OF
STRUCT\JMS OVER 3 STOAIES IN HEIGHT DECLARATIONS ARE TRUE AND CORRECT AND I FURTHER CERTIFY AND AGREE IF A PERMIT IS h mil IS not commenced *lth,n 180 days from tne dale of such
ISSUED TO COMPLY WITH ALL CITY COUNTY AND STATE lAWS GOVERNING BUILDING CON or
STRUCTION WHETt-!ER SPECtF:ED HEREIN OR NOT I ALSO AGREE TO SAVE INDEMNIFY AND ~z.:=::':':'1:-':'~!:.:!:-"::;i:;,r:~7:J-=====~~~~!!...!;!!!!.!~L----:----,~~~----------------------
KEEP HARMLESS Tt-!E CITY OF CARLSBAD AGAINST ALL LIABILITIES. JUDGMENTS, COSTS AND APPROVED BY DATE
EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE
GRANTING OF THIS PERMIT ,r _._.....,_,,,, ;?"-'_,.._______ BY PHONE 0 ~-
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TYPE ' DATE INSPECTOR
BUILDING I , cg~ --;;., ).-;).I./) f~
FOUNDATION I
I FIELD INSPECTION RECORD
REINFORCED STEEL I
MASONRY I -
GUNITE OR GROUT I
I
REQUIRED SPECIAL INSPECTIONS INSPECTOR'S NOTES
INSPECTION REO IF INSPECTORS DATE CHECKED APPROVAL
FLOOR & CEILING SUB FRAME I
SOILS COMPLIANCE
SHEATHING D ROOF D SHEAR PRIOR TO
FRAME I
I
EXTERIOR LATH !
FOUNDATION INSP
STR UCTURAL CONCRETE
OVER 2000 PSI
INSULATION I
INTERIOR LATH & DRYWALL I
I
PRESTRESSED
CONCRETE
POST TENSIONED
I CONCRETE
PLUMBING I
I FIELD WELDING
SEWER AND BUCO D IPUCO I
I
UNDERGROUND D WASTE D WATER
HIGH STRENGTH
BOLTS -
TOP OUT D WASTE D W"TER SPECIAL MASONRY
TUB AND SHOWER PAN I
I
GAS TEST I PILES CAISSONS
D WATER HEATER D SOLAR WAjrER
I
I
ELECTRICAL I ---
D ELECTRIC UNDERGROUND D ~FFER
ROUGH ELECTRIC I
I
D ELECTRIC SERVICE D TEMPORARY
D BONDING D POOL I
I
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MECHANICAL I
D DUCT & PLEM., D REF. PIPING
HEAT -AIR COND. SYSTEMS I .
VENTILATING SYSTEMS I
I
I I
.. -
CALL FOR FINAL INSPECTION WHEN ALL APPROPRIATE
ITEMS ABOVE HA VE BEEN APPROVED.
FINAL
PLUMBING ---' ' . "'
ELECTRICAL ' ... ,.., '" < ( . -MECHANICAL .,
GAS ' . -
BUILDING I
SPECIJ\L CONDITIONS ,. I
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O I hereby lfflrm that I am licensed under
provlalona 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.
lot No ______ Cla,s
I hereby alfirm that I am exempt from the Con!rac· tor's license Law tor the tollowmg reason (Sec 7031 5 Business and Professions Code Any city or county wt11cn re-
quires a perm11 to coos1<uc1. a!1er. improve. demohsh, or repair any structure. pr!Of to 11s ,ssuance also requires !heap-
plicant for such permII to ftte a signed statement !hat he Is hcensec, pursuant 10 lhe prov,s.ions of the Con1racIofs
Ltcense Law (Chapter 9 commencing with Sect10n 7000 ol Divis.on 3 ol the Bus-ness and Profess100s Code) or that Is ex-empt !heretrom and the baSIS lor lhe allegeo exemphon Any
v1olahon ot Section 7031.5 by an applicant lor a permit sub-Iects the apphcant to a civil penalty of not more than five hun-
dred dollars (S500)
D I. as owner ol the property, or my employees wuh wages
as theff sole compensation. w,11 do the work, and lhe struc· ture is not intended or of1ered for sale (Sec 7044, Busmess
and Prolessions Code. lhe ContracIoc's License Law does nol apply to an owner of property who builds or improves
thereon and who does such work h,msetf or through htS own employees. provided that such improvements are not intend·
ed or offered for sale. If, however. the building or ,mprove· ment ,s sold within one year at complet.on, lhe owner-builder
will have the burden of proving that he did not build oc 1m• prove 10< the purpose ol sale)
D I. as owner of the property. am exclusively contracting with licensed contractors to construct the pro,ect (Sec. 704-4,
Business and ProtessK>ns Code: The Contractor's License Law does not apply to an owner of property who buUds or in,.
proves thereon. and who contracts tor each projects w,th a contractor(s} license pursuant to the contractor's license Law)
D As a homeowner I am improving my home, and the lotkJw·
ing condiOons exist: I. The work ,s being performed pnor to sale.
2. I have lived in my home tor twelve months prior to completion ot this work.
3 I have not claimed this exemptkN'l during the las! lhree years.
g M:,e:,•;:t under Sec. ______ , B & P.C.
-------------
0 I hereby affirm that I na.-e a certificate ol consent
to self.insure. or a cer11t1ca1e ot Workers Compensation Insurance. or a cer1,f,ed copy thereof
(Sec 3800. Labor Code)
POLICY NO
COMPANY
□ Copy IS filed Wtth the City r
0 Cer11hed CoPY IS hereby furnished
CERTIFICATl OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(fh,s section need not be compleled •' the perm,1 ,s tor one hundred dollars ($100) or less}
0 I cen1ty tha1 ,n !he pertormance ot lhe wont lor which this perm,, ,s ,ssued. I shall not employ any
person ,n any manner so a.s to beeome sub1ec1 10
the Workers· Compensahon Laws ot Calltorna.
NOTICE TO APPLICANT II. after makin~ lh1s Cer11
hcate ol Exempllon. you should t>ecome subJecl I? the Workers· Compensar,on provisions of lhe Labot
Code. you must forth--.,th comply w,lh such
provisions or 1h1s perm,t shall be deemed ,e'-'0ke<J
0 I hereby affirm that !here ,s a cons1tuct1or,
1ending aoency tor the performance ot lhe -Nork to,
wl"uch this permit 1s issued tSec .)()97 C,v,I Codel
Lenders Name ___________ _
Lenoe,·s Address --'----------
USE BALL POINT PEN ONLY & PRESS HARD APPLICANT TO FILL IN INFORMATION WITHIN SHADED AREA AND DECLARATIONS.
CARLSBAD BUILDING DEPARTMENT APPLICATION & PERMIT
_ 1200 Elm. Carlsbad. California 92008-1989 (619) 438-5525
JOB ADDRESS ST.RO. DATE Of APPLICATION VALUA TION PERMIT NUMBER o u~ ~
LOT I BLOCK -L..----o:-------'--------,----------,,_~,s...~1ou:....!.~:LJ~...:::J:'-J~~...:;~--4,...c;;.1w__.:..,....&;~~t,:1.~!1!'~ --
ZONE
PLAN 1.0. #
{J-)'?I~
BL OG USE CODE
WNER' MA LING ADO ESS
210 'I ~1¥1KT ~t/4 D SCRIPT ION Of WORK .-'
~ I OESIGNE.R"S ADDRESS
➔ --------1 f /P FLA ELEV.
vO NO ---
CENSUS TRACT I G P LAND USE I PARKING SPACE RES UNITS 1 GRADING PERMIT ISSUED
YO ND I REDEVELOPMENT
AREA
vO NO
QTY. PLUMBING PERMIT -ISSUE QTY.I MECHANICAL PERMIT· ISSUE
EACH FIXTURE TRAP I 7 I I INSTALL FURN. OUCTS UP TO 100,000 BTU
7f!.-
EACH BUI LO ING SEWER I I I ·ovER 100,000 BTU
EACH WATER HEATER ANO /OR VENT I I I BOILER/COMPRESSOR UP TO 3 HP
EACH GAS SYSTEM I TO 4 OUTLETS I I I BOILER/COMPRESSOR 3-15 HP
EACH GAS SYSTEM 5 OR MORE I I I METAL FIREPLACE
--,;jQ
STORIES
OESIGNER"S Pt<ONE
OCC GP EDU
STANDARD PLAN# BUILDING SO. FOOTAGE
2/._7/r,;4<:Lt .. '-I •.;, •
TYPE occ LOAD FIRE SPR I -' --
CONST .J t • ~ . , , . I;•!,• vO NO Not Valid Un~s Machine Certdttd ~------------
3 -SUMMARY/ACCOUNT NUMBER
BUILDING PERMIT 01 ·00·00·8220
SIGN PERMIT 01·00·00·8221
PLAN CHECK 01 ·00·00-8806
TOTAL PLUMBING 01·00·00·8222
ELECTRICAL 01 ·00·00·8223 I _/ .;-3"
•.«r"••11r•1 01 ·00·00·8224 EACH INSTAl . ALTER, REPAIR WATER PIPE VENT FAN SINGLE OUCT mLv .. nn,vnL
EACH VACUUM BREAKER MECH EXHAUST -HOOO/OUCTS MOBILEHOME 01 ·00·00·8225
WATER SOFTNER I ~ I I RELOCATION OF EA FURNACE/HEATER MOBILEHOME PARK INSP
EACH ROOF DRAIN (INSIDE) SOLAR 01 ·00-00-8226
TOTJ;L MECHANICAL STRONG MOTION 80·92-33-0519
TOT AL PLUMBING l FIRE SPRINKLERS 01·00·00·8227
QTY. ELECTRICAL PERMIT • ISSUE <-QTY. I SOLAR· ISSUE PUBUC FACILITIES FEE 32·00-00-8933
BRIDGE FEE
NEW CONST EA AMP1SWT 1BKR {~i / ,e;ZI ..-, COLLECTORS SCHOOL FEE • DISTRICT
1 PH 3 PH STORAGE TANKS Carlsbad 80·92·21·0519
EXIST BLOG EA AMP/SWT/BKR ROCK STORAGE Encinitas 80-92-22·0519
I PH 3 PH PUMP San Dieguito 80-92-23-0519
AEMOOEL "ALHA PEA CIRCUIT PLAN CHECK FEE San Marcos 80·92-24-0519
TEMPPOLE 200AMPS
OVER 200 AMPS LICENSE TAX 01-00-00-8162
TEMP OCCUPANCY 130 DAYSI
CREDIT DEPOSIT
TOTAL ELECTRICAL 1 /S-s' TOTAL SOLAR TOTAL FEES PAYABLE I /S-~-
I HAVE CAREFULLY EXAMINED THE COMPLETED ··APPLICATION AND .PERMIT" ANO 00 HEREBY E..,.,..,,.. E~ permit tSSUe<I by the Bu1tdtng0ff1c1et under the provisions of1t>1s CERTIFY UNDER PENALTY OF PERJURY THAT ALL INFORMATION HEREON INCLUDING THE Cade.111111 ••11tre by lim,tation and become null and void II the building or work * A_N ~ PEMIIT IS REOUlflED FOR EXCAVATIONS OVEfl
DECLARATIONS ARE TRUE AND CORRECT AND t FURTHER CERTIFY ANO·AGREI! IF A PERMIT IS .. IIIOf,ad by IUCh permit•• nor commenced wrth1n 180 days from the date ~f such 5 0 DEEP AND DEMOLITION OR CONSTRUCTION OF
1 ISSUED TO COMPLY WITH All CITY. COUNlY ANO STATE LAWS GQiftRNING BUtLOING CON-L!~;;;~ldOl~:C,~~•~~lhe~;;bu~lf;d•~ng~o~r~•~o~rk~au~IGh~0<~1Z~ed!!!!;by~sujc~hi:J..pe,~m~•~t [.''2L•u~a~pe~ndedll~o~r rb~~;S;T;:;TURES:=~°":E~fl~3:.:;ST~OAIE;:S~t=N~H:E:IG:H~T---,.---.J
I STRUCTION, WHETHER SPECIFIED HEREIN OR NOT. I ALSO AGREE TO SAVE INDEMNIFY AND ,.....,,.u.,_ time after the worl< 11 commenced fo,'1 Nod of 180
I KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES,JUOGMElfTS. COSTS ANO S SI RE • OWNER 0
I EXPENSES WHICH MAY IN ANY'WAY ACCRUE AGAINST SAID CITY' Qt,.CONSEQUENCE OF THE ,
I . GRANTING OF THIS PERMIT • BY PHONE 0
I
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..1 '-.... _ ·, ., ·.•,,·
':"" .. ~s-':)..-11-.:ie, .., ~ . BUILDING i ' . ' . I
FOUNDATION ' FIELD INSPECTION RECORD I
REINFORCED STEEL !
MASONRY i REQUIRED SPECIAL INSPECTIONS INSPECTOR'S NOTES
' INSPECTION REO. IF INSPECTORS DATE GUNITE OR GROUT I CHECKED APPROVAL -FLOOR & CEILING SUB FRAME I
SOILS COMPLIANCE SHEATHING D ROOF D SHEiAR PRIOR TO
FRAME : FOUNDATION INSP
EXTERIOR LATH I STRUCTURAL CONCRETE
OVER 2000 PSI
INSULATION I PRESTRESSED I
I CONCRETE ,. INTERIOR LATH & DRYWALL I POST TENSIONED
I CONCRETE ' I . PLUMBING ~-\ • ~IEC.-0 WELQING I
SEWER AND BUCO D IPUCO r I '•· HIGH STRENGTH I BOLTS UNDERGROUND D WASTE D WATER I
TOP OUT D WASTE D Wpt\TER SPECIAL MASONRY I .
TUB AND SHOWER PAN I
I
GAS TEST I PILES CAISSONS
D WATER HEATER D SOLAR W)\TER
J I " ..-ELECTRICAL I : ~ ---:,
D ELECTRIC UNDERGROUND D ~FFER -'
ROUGH ELECTRIC I
I ' ..
D ELECTRIC SERVICE D TEMPORARY .
D BONDING D POOL ---~-I -"' ~--
I
I
MECHANICAL I r. I --7 • •. D DUCT & PLEM., D REF. PIPll',IG . ·-·
HEAT -AIR COND. SYSTEMS I
~ . ...
VENTILATING SYSTEMS ·' ' I
CALL FOR FINAL INSPECTION WHf..N AU APPR'l_P~TE .. ,· , ... i . ITEMS ABOVE HAVE BEEN·APPROVED.-•·j ' 'I': • ·-\ FINAL '-• ~ JI' I -...., r-\ '· ' l'--i \ •. -:: •' ' ' -,°!'·., '\( -., .\. l -... , \-• \ ' ' ·, \ ... -~:}: -·-. ' .> ' PLUMBING I I ~'I •• '.1 T l1I~..,. '· • •• ' \ •· '. .• '( \. , I I \ \ •. .. \ -. " ,..
ELECTRICAL I f1 I 0/1" A I ' -:)\.,~~\r ..... ,,,<" ·, ·..: ,.,_ __ '\' >-\· • • ._: ... • .. '-
11 i.l 11 ....,., w ' ':~ ,. 't .. " .. MECHANICAL I . C •-'\: • ', :-1 I
I • ;::_,.·,..... -. \ '\~-~' ' • •·~•-., \ \, -GAS ,-1 '.\f.. .. \,\".~. ;'-·)...,: . ; ~ .. .. I .. ~' ' ! BUILDING ! • J l
SPECIAL CONDITIONS I ' I UI...
~ !
I
City of Carlsbad
APPLICATION FOR CERTIFICATE OF OCCUPANCY
BUILDING DEPARTMENT
1200 ELM 438-5525
Address where Business
will be conducted
Name of Occupant
Address of Home Office of
Occupant if different from above
Owner of Building
Type of Business
IT
Describe exact use of all portions of each building and lot
Previous use of Building
Type of flammable or explosive liquids to be used, If any
S o tv re c=.S Address
11/e;llJG
VALIDATION
Building
Permit No.
Home Office
Phone
Phone II .J-6Soo
E.
I certify that I have read the statements contained in this application; that they are true and correct, and that I make this statement under penalty of perjury.
Dated this
Signature of
Applicant
Use Zone
Planning ..-l O Department ~
Engineering
Department
Fire ..,
Prevenlton
Health
Department
Building
Department
, 19
Signature of Building Official
FOR DEPARTMENTAL USE ONLY
Occupancy Group Type of Construction
Disapproved By
Disapproved By
Disapproved By
By
By
White -Building Dept. Yellow -Applicant Pink -Finance Gold -Fire Dept.