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1)(1 I hereby affirm that I am licensed under
provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business
and Profeaslons Code, and my license is In
~~:I !~rc'Jrfr'!> ltm <2.. 3 G,
I hereby alhrm that I am exempt from Ihe Conlrac·
to,· s lttense law for the lOUow1ng reason (Sec 7031 5 Business and Prolesst0ns Code Any c11y or county whtth re,
quires a perm11 10 construct. alter. improve demolish, or repair any structure. pnor 10 ,ts issuance arso requires !heap·
pt.cant tor such permlf 10 Me a s19nect sta1ement that he 1s
licensed pursuant to the provIsI0ns ol lhe tontracIor· s
license Law (Chaple, 9 corrmertcmg Wllh SecllOO 7000 of 01v1s1on J ol lhe Business and Protess1ons C()(jeJ or 1na11s ex
empt lheretrom and lhe basis for lhe allegea exemphen Any
v101at1on ol Secl!on 7031 5 by an apphcanl tor a permit sub
Jects the appbcant to a civil penally of not more lhan five hon
dred dollars ($500)
I, as owner ot the properly, or my em~oyees w11h wages
as their sole compensation, w ti do the work and the struc-
ture ,s not intended or ollered tor sa~ (Sec 7044 Business
and Prolesst0n5 Code The coniractor·s License Law does
not appty ro an O'Nner of properly who bu1K1s o, improves
!hereon and who does such work h1msell or lhrOUgh his own employees. provided lhal such Improvements are not intend-
ed °' ottered IOJ sale II. however. the building or 1mpro•:e-men1 1s sokJ w1th1n one year of compieuon !he owner·OU•lder
vnll have the burden of proving that he did not bu1kS or im-
prove 101 !he purpose ol saleJ
I, as owner of lhe propeny, am excluswety contracting w11h ltcensed contractors 10 consttucl lhe pro,ect (Sec 70-44
Busmess and Proless1ons Code The Conuactofs License Law does not apply lo an owner ot property who builds or ,m proves thereon. and who contracts lor each proiects w11h i
contractor(s) license pursuan1 10 the Con1rac1or·s License Law)
n As a homeowner I am improvmg my home, and the !allow•
Ing cond1l10ns ex,sl I The WOik IS t>emg performeo pr,or ID sale
2 I have lived 1n my home for twelve months
3 r:v~ ~1:p~~:e:f 11~:: :!~phon during the
last three years
~r 11h~: ,i~:ae;:1 under Sec _____ _ B&PC
C I hereby alt.rm that I have a cenillcate of consent to
self insure. or a certificate of Workers Compensation In•
SUfance. or a cerlilted copy thereof tSec. 3800. LabOr Code)
POLICY NO
COMPANY
:J Copy is filed with lhe city
:J Cer11lled copy 1s hereby furnished
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
(This section need not be compfeted ii the perm11
t. 1s for one hundred dollars (S100) or lessl
I certify !hat in the pet"formance ot the work for which
perm,t 1s Issued, I shall not employ any person in any
manner so as to become subject to the WOfkers' Compen-
sation Laws of California.
NOTICE TO APPLICANT: If. after maktng this Certificate
of Exemption. you should become subject to the Workers·
Compensation pcov1s1ons of the Labof Code. you must
forthwith comply w,th such provisions or Uus permit shall
be deemed revoked
0 I hereby af!irm that there is a construction lending
agency for the pefformance of the wor1<: for which this per-
mit ls ,ssuecl (Sec. 3097. Clvil Code)
Lender's Name ____________ _
Lender's Address _______ ~~---
USE BALL POINT PEN ONLY & PRE~S HARD APPLICANT TO FILL IN INFORMATION WITHIN SHADED AREA AND DECLARATIONS. -.... --. ·---
I CARLSBAD BUILDING DEPARTMENT I APPLICATION & PERMIT I Carlsbad, California 92008-1989 (619) 438-5525
I
JOB A~ORESC 7 ~ ?-// 1 /I-_ -~0 7:! 1~,eR~SS ST l0:;µp37;} I BUSINESS LICENSE " VALUATION ,. ):.iRMIT NUMBER
l~b/p/j &,
LOT BLOCK I SUBOI VISION I ASSESSOR PARCEL NO CONTRACTOR . CONTRACTORS PHONE • ZONE
OWNER'S NAME I '-l.'1¥N7U7 Cle.tJ(A.//V ~L4 "1 (! "/Y2 0 "') '-/ 7...
,,,?JJttf.k n, ,,,1 l.--L fo /( CONTRACTOR'S ADDRESS ~ LIC:}SE/~ r 3 / PLAN 1.0. # BUILDING SO. FOOTAGE
6'?2 ,_
OWNE.A:'S MAIL NG ADDRESS
DESIGNER DESIGNER'S PHONE
DESCRIPTION OF WORK
DESIGNER'S ADDRESS LICENSE NO .
.--C?JI._S l'eE ~lf./rz F p F LR ELEV NO OCC GP EDU 6/28/Lu \l,;l'.. 10a!J STORIES
vO NO (!QI.J1. f~b4 ;;J/,;;.(J/ IJ[; ID~J'
C~NSUS TRACl I GP LANO USE I PARKING SPACE RES UNITS I GRADING PERMIT ISSUED
I
REDEVELOPMENT TYPE OCC LOAD FIAESPR
AREA CONST
'0 N 0 ,o "o vO NO N r Valid Unl~r Machme Certd1ed
QTY. PLUMBING PERMIT · ISSUE ~ QTY. MECHANICAL PERMIT· ISSUE ~ / SUMMARY/ACCC UNT NUMBER
EACH FIXTURE TRAP I INSTALL FURN. DUCTS iJP TO 100 000 BTU BUILDING PERMIT oq1-8Hr· ~-8220
EACH BUILDING SEWER OVER 100 000 BTU SIGN PERMIT 00N3fl-~0-8221 ---llQ,,1-~)q-op"'.' oo-8soo -
EACH WATER HEATER ANO OR VENT BOILER/COMPRESSOR UP TO 3 HP PLAN CHECK "'-
EACH GAS SYSTEM 1 TO 4 OUTLETS --+-., ."i{ BOILER/COMPRESSOR 3 15 HP TOTAL PLUM BIN~""-\. 0!)1~-"bb-oo-8222 Jl7j_OQ_ -~ , o'&'lis10-oo-oo-a223 EACH GAS SYSl EM ~ OR MORE METAL FIREPLACE ELECTRICAL
EACH INSTAl , ALTER, REPAIR WATER PIPE VENT FAN SINGLE DUCT MECHANICAL , J \~J-810-00-00·8224 -
EACH VACUUM BREAKER MECH EXHAUST HOOD OUCTS MOBILEHOME ~ o~lh-O-oo-oo-8225
I WATER SOFTNER RELOCATION Of EA FURNACE1HEATER MOBILEHOME PARK 11>1 P
I
I EACH ROOF DRAIN (INSIDE1 SOLAR 001-810·00·00-8226
I TOTt;L MECHANICAL STRONG MOTION J 880·519·92·33
I I 7D ~---
I TOl AL PLUMBING FIRE SPRINKLa,,._ 001·810-00-00·8227
I f✓ PUBLIC FACILIT~"" ' 332-810·00·00·8930
I QTY. ELECTRICAL PERMIT · ISSUE QTY. SOLAR • ISSUE ~ \ I
I NEW CONST EA AMP SWT BKR COLLECTORS SCHOOL FEE -lllsJRICT -I I PH 3 PH STORAGE l ANKS Carlsbad
___,
EXIST BLOG EA AMP,SWT BKR ROCK STORAGE Encinitas
I PH 3 PH PUMP San OieguIto
REMODEL ALTtR PER CIRCUIT PLAN CHECK FEE San Marcos
TEMP PO LE 200 AMPS
OVER 200 AMPS LICENSE TAX 001-810·00-00·8162
TEMP OCCUPANCY 130 OAYSl MFF 880-519-92-57
CREDIT DEPOSIT
TOTAL ELELTRICAL l TOTAL SOLAR TOTAL FEES PAYABLE I /0,DD
I HAVE CAREFULLY EXAMIJl;EO THE COMPLETED ·APPLICATION ANO PERMIT'" ANO 00 HERES'( Expsrat1on Every permit issued bytrte Bu1ld1ng OU1c111 under tneprt1s1ons.of~~,s * AN OSHA PERMIT tS REQUIAf0 FOi! EXCAVATIONS OVER
CERTIFY UNDER PENALTY OF PERJURY THAT ALL INFORMATION HEREON INCLUDING THE Code shall e>tptre by ltm,tatton and become null and void If the bu•ld1ng or work 5 O' DEEP ANO DEMOLITION OR CONSTRUCTION OF
DECLARATIONS ARE TRUE ANO CORRECT ANO I FURTHER CEA,IFY ANO AGREE IF A PERMIT IS authorized by such perm11 ,snot commenced w1th1n 180 days from lhe date of sucn / STRUCT\JR£S OVER l ST~ IN HEIGHT
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r_ permit. ';;J', t the bu1ld1~or wor~ authorized by such permit ,s suspended or ISSUED TO COMPLY WITH All CITY COUN1Y AND STATE LAWS GOVERNING BUILDING CON abandon at anv tune a r u,e work ,s commenced for a oenod of 180 d•"·
STRUCTION, WHETHER SPECIFIED HEREIN OR NOT I ALSO AGREE TO SAVE INDEMNIFY AND 7' 57'_ OWNE~ CONTRACTOR C ~ X (), /1 °cf-~3-F('' KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES JUDGMENTS_ COSTS ANDI~' NT. s SIGNAT E • ,L..-s:
EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE • BY PHONE 0
I GRANTING OF THIS PERMIT • -:., ~ A
I -✓ ,✓ ·77 --