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A APPROVAL
IN SP. -_ DATE <t-r-?s-93
CLEA NCE -i-;Ji <73
CITY OF CARLSBAD
2075 Las Palmas Dr., Carlsbad, CA 92009 (619) 438-1161
PERMIT APPLICATION PI.AN CHECK NO.
City of tarlsbad Building Depart-,-.t
2075 Las Pal.as Dr., tarlsbad, CA 92009 (619) 438-1161 EST.VAL._ _________ _
PLAN CK DEPOSIT _______ _
VAIID.BY ___________ _
DATE'---------------
A -D Commercial LI New Building D Tenant Improvement
B -D Industrial □ New Building D Tenant Improvement
C -)\Residential D Apartment ""'Condo □ Single Family Dwelling □Addition/Alteration
□ Duplex □ Demolition □ Relocation □ Mobile Home D Electrical .!:!{Plumbing
□ Mechanical O Pool O Spa O Retaining Wall O Solar □ Other ____ _
2. PROJECT INFORMATION FOR OFFICE USE ONLY
Building or Suite No.
Nearest Cross Street
LEGAL DESCRli>'tioN Lot No. Subd1vts1on Name/Number Unit No. Phase No.
CHECK BEillW IF SOBMII IED:
□ 2 Energy Gales □ 2 Structural Gales D 2 Soils Report □ 1 Addressed Envelope
EXISTING USE PROPOSED USE
NAME
CITY STATE
ADDRESS
ZIP CODE DAY TELEPHONE
4. APPUCAN I
NAME
II cON I RAC !OR □ AGEN I FOR cON I RAC IOR
ADDRESS
DOWNER □AGENI FOR OWNER
CITY STATE ZIP CODE DAY TELEPHONE
S. PIIDP'-t OWNER
NAME /We --YoNt'U ADDRESS )et q SO P,e:. k ,; rf $ r
STATE ,/~
f'lu 1M 6 ,;,ttJ
STATE e./.:>
STATE UC. # 'J3')6//
ZIP COD AY TELEPHON
ADDRESS A,/() /,M1rll?Ofl1
ZIPCODE ~')V.IJ DAY TELEPHONE 7;)( ~ ")')')/
LICENSE CLASS <:,. :J' CITY BUSINESS UC. # f ~ 4/ J (
DESIGNEH NAME ADDRESS
CITY STATE ZIP CODE DAY TELEPHONE STATE UC. #
1. WOIUMtS' wMP£NSXl10N
Workers' COmpensauon bedarauon: I hereby all1rm that I have a certificate of consent to sell-insure issued by the Director ol Industnal
Relations, or a certificate of Workers' Compensation Insurance by an admitted insurer, or an exact copy or duplicate thereof certified
by the Director of the insurer thereof filed with the Building Inspection Department (Section 3800, Lab. C).
INSURANCE COMPANY
Cerulicate of Exemption: I ce
so as to become subject t t
POLICY NO. EXPIRATION DATE
fy that in the performance of the work for which this permit 1s issued, I shall not employ any person in any manner
rkers' Compensation Laws of lifomia.
D
□
D
ere ya irm t at am exempt rom e ntracto s cense w or t e o owing reason:
I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure is not intended or
offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds
or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended
or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden
of proving that he did not build or improve for the purpose of sale.).
I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and contracts for such projects
with contractor(s) licensed pursuant to the Contractor's License Law).
I am exempt under Section _______ Business and Professions Code for this reason:
(Sec. 7031.5 Business and Professions Code: Any City or County which requires a permit to construct, alter, improve, demolish, or repair
any structure, prior 10 its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the
provisions of the Contractor's License Law (Chapter 9, commencing with Section 7000 of Division 3 of the Business and Professions Code)
or that he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500]).
SIGNATIJRE DATE
COMPLETE 'l'Als SEG'lloN FOR NON-RESIDENTIAL BUILDING PERMITS ONLY:
Is the applicant or future building occupant required to submit a business plan, acutely hazardous materials registration form or risk management and
prevention program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act?
□ YES ONO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district?
□ YES □ NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site?
□ YES O NO
IF ANY Of TI lE ANSWERS ARE YF.S, A FINAL CERllFICATE Of cxx:uPANCY MAY NOf BE ISSUED AFIER JULY 1, 1989 UNI..ES.5 TilE APPUCANT
HAS MET OR IS MElmNG TIIE RF.QUIREMENTS OP TIIE OFFICE OP EMERGENCY SERVICES AND TIIE AIR POlLUTION CDNTROL DISTRICT.
9. OONS'I k0Ci1ON UlNDINC AC£NcV
I hereby athrm that there 1s a construction lending agency for the performance of the work for which this permit 1s issued (Sec 3097(1) Civtl Code).
LENDER'S NAME LENDER'S ADDRESS
to. APPLICANT CE1t'm'ICA'l1ON
I ceruty that I have read the apphcauon and state that the above mlormauon 1s correct. I agree to comply with all City ordinances and State laws
relating to building construction. I hereby authorize representatives of the City of earls bad to enter upon the above mentioned property for inspection
purposes. I AlSO AGREE 10 SAVE INDEMNIFY AND KEEP HARMLF.SS TIIE CTfY OF CARISBAD AGAINSf AIL UABIUTJES, JUDGMENTS, CDSTS
AND EXPENSF.S WIDCH MAY IN ANY WAY Aa:RUE AGAINST SAID CTfY IN CDNSF.QUENCE OF TI-IE GRANTING OF TI-US PEJlMIT.
OSHA: An OSHA permit is required for excavations over 5'0" deep and demolition or construction of structures over 3 stories in height.
Expiration. Every permit issued by the Building Official under the provisions of this Code shall expire by limitation and become null and void if the
building or work authorized by such permit is not commenced within 365 days from the date of such permit or if the building or work authorized by
such permit is suspended or abandoned at any time after the work is commenced for a period of 180 days (Section 303(d) Uniform Building Code).
DATE: tf-;>s;.C(J APPLl
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WHITE: File YEU.OW: Applicant PINK: Finance