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CITY OF CARLSBAD—BUILDING DEPARTMENT W ADDI l,ArI(Tht 2 DOkAIT APPLICANT TO FILL IN INFOR -
LICENSED CONTRA,-' DECLARATION FI'/\t ILJt'e t Lt\iVtl I -- - - - -
thereby affirm. that 'osod under provi- USE BALL POINT PEN ONLY 1200 ELM AVENUE (714)438-5525 MATION WITHIN RED LINES.
mona of Chapter 9 (c '-. .'rg with Section ______ _
7000) of Division 3 of I' j 'neSs and Protc,s-
slona Code, and my lice-.. ' lull force and et-
feet.
OWNER BUILD(i-i ('I - ODATION
Dl hereby affirm that 1 ,-'i i -.- . I from the Con-
tractor's License law C '- '011owing reason
(Sec. 7031 .5 Business .vn. ,' .'3sinas Code), Any
city or county which ru S ' i permit to con-
struct, alter, improve .- Dr. or repair any
structure, prior to its is' .. . aiso requires the
i5llcant for such peim I t',.i a signed state-
ant that he is licensed S .rrit to the prod-
ons of the Contractor's . -o Law (Chapter 9
commencing with Sect'. n of Division 3 of
the Business and Proles - •.-de) or that is ex-
empt therefrom and tire ' i the alleged ex-
emption Any violation ci '031 5 by an ap-
plicant for a permit sut.- c applicant to a
civil penalty of not more l' . ' -.,' 'sundred dollars
($500).
LI, as owner of the pro c , or my employees
with wages as their Sc - C. v'rsation, will do
the work, and the stri..c -cl intended or of-
bredfor sale (Sec 70I.: c-va and Protes-
sioris Code: The Cor-Ira ' . vnso Law does
not apply to an owner C ' . . ry who builds or
improves thereon and .- I", such work
iiirnsolt or through tus iQ5-e5, provided
that such improvemen" --'- D 'nlended or of-
fared for sale It, trowc-c.r- ..ding or improve-
mont is sold withn ui'i-, completion, the
owner-builder will hare' : -i of proving that
he did not build or in .''lhe purpose of
sale).
as owner ol the pi -i -',. i exclusively con-
trading With liCiiflsicO L i ii. 'is to construct
'he project )ec, 7044. B ..---.-end Professions
e. The Contractors r.''c- law does not ap-
to an owner of por.5-t- • so builds or mi- ' xl
.rive3 thereon, and who -i-r" iscls for such pro-
jects with a coritractoris; : c.;'-,rj pursuant to the
contractor's License Lee.;
I am exempt undyr Or-c , B. & P.0
for this reason_. -
Date ________ .. Cei'er
WORKERS 'COMPENSATION DECLARATION
I hereby affirm that I t.,.e -, certificate of con-
sent to self-Insure, or a c'' c.xle of Workers'
.)
Compensation lnsuraacr r5 a certified copy
thpreot (Soc. 3800. Labor Cc rio).
- P&tCY NO..___
CöMPANY_.
OCopy Is filed with the c
EJCertttied copy Is hieL-y ',irs,shed.
CERTIFICATE Q5 EXE,rPTION FROM
WORKERS' COMPEIrSA'ON INSURANCE
(This section need not 1 r-mpleled it the per-
mit is for one hundred j(5t .....$1001 or loss).
.1 certl'y that in the perlo'-..: cot the work for
w!ich this permit is isu-..i, I :- rd riot employ any
person in any manner so c' ' : -,-come subject to
the Workers' Comporisati.r as t California.
NO. AV ST . ATE OF CArt NT BUS. LICENSE PERMIT NUMBER -
OWNFR OWNER'af-IoN - E CONTRACTOR
OWNER'S MAIL INOODRS5 R'S ES5 CO
N'TRAC TaR'S
- -
Not Valid Unless Machine Certified
LOT I BLOCK I SUBDIVISION ASSESSOR'S PARCEL NO.
I I I I I I I I I
DESIGNER
-
ESIGNEF(
fL
ADDR
STATE 1:ICENSE
/ 'S SIGNER'
__________--
CENSUS TRACT OP LAND USE ZONING [RES. UNITS PARKING
I
BLDG 50. FT. BLDG USE 0Cc. OP STANDARD PLAN # PLAN 0 ft
/_
TYPE CONST jOCc. LOAD
-
-
valuation -"O,&O
lilY. PLUMBING PERMIT AMT.
-
QTY.
_
MECHANICAL PERMIT AMT.
EACHFIXTURETRAP . INSTALLFURN.DUCTSUP TO100,000BTU
EACHBUILDINGSEWER . OVER 00,0Q0BTU
EACH WATER HEATER AND/ORVENT BOILER/COMPRESSOR UP TO 3 HP
EACHGASSYSTEMITO4OUTLETS . BOILER/COMPRESSOR3-15HP
EACHGASSYSTEM5ORMORE , BOILER/COMPRESSOR16-30HP *
EACHINSTAL.,ALTER, REPAIR WATERPIPE . VENTFANSINGLEDUCT
- EACHLAWNSPRINKLERSYSTEM . - MECHEXHAUST — HOOD/DUCTS .
- WATERSOFTNER , RELOCATION OFEAFURNACE/HEATER . BUILDINGPERMIT I
.4.ssue .3JI( 3,,00 1 SIGN PERMIT •_iI'_.I - TOTAL PLUMBING
CONTRACT OR -
TOTAL MECHANICAL
CONTRACTOR - '
PLAN CHECK
__
ALLINCLUSIVEPERMIT S--
l y. ELECTRICAL PERMIT AMT. lily, - MOBILE HOME PERMIT AMT. TOTAL PLUMBING
NEW CONST EA AMP/SWT/BKR . - — AWNING . MECHANIC
PH.25 3P1-I . - PORCH , MOBILEH2!_ EXIST BLDG EA AMP/SWT/BKR . SET-UP • SOLAR
IPH.25 3PH . RAMADA, CABANA .-
12t1-fr(,..
Stroric.lvi
REMODEL/ALTER PER CIRCUIT , - FENCE OVER 6' .
_
5-
TEMPPOLE200AMPS . TOTALMOBILEHOME , NIC 0-FILM OVER200AMPS TEMP OCCUPANCY 30 DAYS)
2,00
TOTAL ELECTRICAL --
CONTRACTOR
.
TOTAL
I L t _
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