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0 I hereby affirm that I am licensed urider
provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business
and Professions Code, and my license Is In
lull force and effect.
Lie No __ __ Class __ _
I hereby att,rm that I am exempt from the Con-
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county wtuch requires a permit to construct alter. ,mpnwe, demohsh, or repan any structure, pnor to its issuance also requires the ,c:,plicant for
such penmt to hie a s19ned statement that he 1s
lteensed pursuant to the pr0Y1s1011s of the Con tractor's Ltcense Law (Chapter 9 commencing with
SecttOfl 7000 of Otv1s,on 3 of the Business and Pm-
fesstons Code) or that 1s exempt therefrom and the
b&s1s for the alleged exemptt<>n Any vK>lateon of
SectlOO 7031 5 by an ~!Cant lo, a permit SUl>fe<:IS tne illPPhcant to a crv11 penalty ot not more than five
hundred dollars ($5(X)).
D I, as owner of the property, Of my employees ,.,th wages as their sole compensation, will do the WOtk, and the structure 1s not intended or ottered for
sale (Sec ~. Business and ProfessK>hs Code· The Contractor's License law does not apply to an
owner of property who builds or 1mp,oves thereon and who does such wOf1t himself or through his own employees, pr0Y1ded that such ,mproyeme:its are
not intende1 Of ottered tor sa~ If, however. the building or improvement 1s sold within one ye. of completion, the owner-builder will have lhe burden of proving that he dtd not build or 1mpr0Ye tor the
purpose ot salel
□ I, ~ owner of the property, am e>cclus,vely contrach~ with lteensed contractors to construct the p,o,ecl (Sec. 70M. Business and Professt0ns
Code: The Contractor's license Law does not apply to an owner of property who builds or 1mprcwes
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license Law).
0 I am exempt under Sec
tor this reason
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□ I hereby affirm that I ha¥e a certificate of consent to self-insure, or a certificate of Workers·
Compensation Insurance. or a cert1fted copy thereof
(Sec 3800.,Labo< Code)
0 Certified CoPY 1s hereby furnished
CERTIFICATl OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed 1f the permit
IS tor one hundred dc)llars ($100, or less)
O t certify that in the performance of the wonc. tor which th,s pemut 1s issued. I shall not employ any
person in any manner so as to beCome sub1ect to the Workers· CompensattOn Laws of Gahtorma
NOTICE TO APPLICANT If. after mak1n~ this Cert, hcate of Exemption, you shoutd beCome subfect 1')
the Workers· Compensation provisions of the ubor
Code. you must tonnw1th comply with such provisions or lh1s permit snall be deemed r~ed
O I hereby attum that 1here 1s a constructtOn
lending agency fOJ the perl04'mance of the wOttt for
wtuch this permit ,s issued (Sec 3CS7. C,v,I Code)
Lenders Name ___________ _
Lender's Address __________ _
y ..... -· .. --. -···· • -·· -··-· -.... ___ ........ -, -
CARLSB)...J BUILDING DEPARTMENT APPLIC~T12J~ ~~RMIT 1200 Elm, Carlsbad, California 92008 (714) 438-5525
JOBJ?;SD VtSfasA-A~i.T., Dj: ~={QNI
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BUSINESS LICENsl ,; VALUATION PERMIT NUMBER
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°]<,/;;J-E Go++6ch a_1 K I 4?l;NER'S P'Z'() p(r;;u;t,7~ 011~ CONTRACTORS PHONE • ZONE
. J5 b •722.-:~
OWNER'S MAILING ADDRESS
cbq()o/1/;,~D~ • (l J f)\P itt ~
LICENSE NO. PLAN I.D. # BLOG USE CODE
.::SArne. ,I\./ A,&)\ft:. n J
LOT I BLOCK I SUBDIVISION I ASSESSOR PARCEL NO. DESIGNER STATE LICENSE# STANDARD PLAN # BUILDING SQ. FOOTAGE
7_4~q</..UJ DESCRIPTION OF WORK
: DESIGNER'S ADDRESS DESIGNER'S PHONE _w~ hectil'Y _ Y4J~1 _ l. 2/QI/G27Q,.., I c. ·J
F/P FLR ELEV. NO OCC GP EDU 000 17676 2/GI/ 82 1r.1
STORIES
vO NO
CENSUS TRACT I GP LAND USE I PARKING SPACE I RES UNITS I GRADING ~ERMIT ISSUED I REDEVELOPMENT TYPE OCC LOAD FIRE SPR AREA CONST
YO ND vO NO vO NO Not Valid Unlffs M.chine <:e,tifi«I
QTY. PLUMBING PERMIT · ISSUE 7<6 QTY. MECHANICAL PERMIT· ISSUE SUMMARY/ACCOUNT NUMBER
EACH FIXTURE TRAP INSTALL FURN. DUCTS UP TD 100,000 BTU BUILOING PERMIT
EACH BUILDING SEWER OVER 100,000 BTU SIGN PERMIT
I EACH WATER HEATER ANO/OR VENT 7-,~ BOILER/COMPRESSOR UP TO 3 HP PLAN CHECK ~
EACH GAS SYSTEM 1 TO 4 OUTLETS BOILER/COMPRESSOR 3-15 HP TOTAL PLUM BING /~;.--
EACH GAS SYSTEM 5 OR MORE METAL FIREPLACE ELECTRICAL -
EACH INSTA~ .. ALTER, REPAIR WATER PIPE VENT FAN SINGLE OUCT MECHANICAL
EACH VACUUM BREAKER MECH EXHAUST -HOOD/DUCTS MOBILEHOME
WATER SOFTNER RELOCATION OF EA FURNACE/HEATER MOBILEHOME PARK INSP
EACH ROOF ORAIN (INSIOE) SOLAR
TOTt.L MECHANICAL STRONG MOTION -TOTAL PLUMBING I 10 .m FIRE SPRINKLERS
PUBLIC FACILITIES FEE
QTY. ELECTRICAL PERMIT • ISSUE QTY. SOLAR· ISSUE BRIOGE FEE
NEW CONST EA AMP/SWT/BKR COLLECTORS SCHOOL FEE • OISTRICT
1 PH 3 PH STORAGE TANKS Carlsbad
EXIST BLDG EA AMP/SWT/BKR ROCK STORAGE ' Encinitas
1 PH 3 PH PUMP • ' San Oieguito
REMODEL/ALTER PER CIRCUIT PLAN CHECK FEE San Marcos
TEMP POLE 200 AMPS
OVER 200 AMPS
TEMP OCCUPANCY (30 OAYS) ·----.
TOTAL ELECTRICAL I I TOTAL SOLAR TOTAL FEES PAYABLE I /()~ ~
I HAVE CAREFUUY EXAMINED THE COMPLETED "APPLICATION AND PERMIT" AND DO HEREBY Exp,ratlOf\ Every permit iaaued by the Bu1ldtng Off1c1al under the prov111ons of this * AN 06HA PERMIT IS IIEOUIAED FOR EXCAVATIONS OYER
CERTIFY UNDER PENALTY OF PERJURY THAT ALL INFORMATION HEREON INCLUDING THE Code shall expire by hm1t1t1on and become null and v01d If the building or work 5· O" DEEP AND DEMOLITION OR CONSTAUCTION OF
DECLARATIONS ARE TRUE ANO CORRECT ANO I FURTHER CERTIFY AND AGREE IF A PERMIT IS authoriZed by such permit 1s not commenced w1th1n 180 days from the date of such STRUCTURES OVER 3 STORIES IN HEIGHT perm,~ or 1f the bu1ldt~or work author!Zed by IIUCh permit 11 auspended or ISSUED: TO COMPLY WITH ALL CITY, COUNTY AND STATE LAWS GOVERNING BUILDING CON· •ban-at anv time the work is commenced for 1 """od of 1 iiit :.,_:,~
STRUCTION, WHETHER SPECIFIED HEREIN OR NOT I ALSO AGREE TO SAVE INDEMNIFY AND APPLICANT'S SIGNATURE • OWNER□ CONTRACTOR 0 APPROVED BY
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KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGMENTS. COSTS AND
114-EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE BY PHONE 0 GRANTING OF THIS PERMIT
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INSPECTION TYPE DATE INSPECTOR 8':)-;t{.o BUILDING
FIELD INSPECTION RECORD
FOUNDATION
REINFORCED STEEL REQUIRED SPECIAL INSPECTIONS INSPECTOR'S NOTES
MASONRY INSPECTION REQ. IF INSPECTOR'S DATE CHECKED APPROVAL
GUNITE OR GROUT SOILS COMPLIANCE
FLOOR & CEILING SUB FRAME PRIOR ro
FOUNDATION INSP
SHEATHING STRUCTURAL CONCRETE
FRAME OVER 2000 PSI
EXTERIOR LATH lNSULATION PRESTRESSED
CONCRETE
INTERIOR LATH & DRYWALL POST TENSIONED
CONCRETE
PLUMBING FIELD WELDING --
SEWER AND BL/CO HIGH STRENGTH
PLUMBING UNDERGROUND BOLTS
PLUMBING TOP OUT SPECIAL MASONRY .
I
TUB AND $HOWER PAN
GAS TEST PILES1CAISSONS .
ELECTRICAL
TEMPORARY POWER :
ELECTRIC UNDERGROUND . -
ROUGH ELECTRIC
ELECTRIC SERVICE
BONDING
G. F. I. -SMOKE DETECTOR
MECHANICAL ..-,
DUCT & PLEM., REF. PIPING
HEAT -AIR COND. -SOLAR SYSTEMS -
VENTILATING SYSTEMS
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CALL FOR FINAL INSPECTION WHEN ALL APPROPRIATE
ITEMS ABOVE HA VE BEEN. APPROVED.
JOB SITE FINAL -PLUMBING ,,, _/__.,,-~ )
ELECTRICAL " -~//n) C y -.,.
MECHANICAL h~./'. Y-~ ,.
GAS ~ ~ ~/\_-"t:>' ~ n~ -~
BUILDING
SPECIAL CONDITIONS --,/1 V
CERT OF qr.~IJPANCY ISSUED '-.,V '
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