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LENDER WORKER'S COMPENSATION , OWNER/BUILDER
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Iffo S3?o? cl? -iO 1 hereby affirm ihai 1 hart a certificate ol consentto self insure or a certificate ol WorkersCompensatton insurance or a certified copy thereof(Sec 3800 Labor Code)POLICY NOtor this reason.1I i!HE t {fill! IJl!!!!1!!!- 11=1 1 |t|g|| iHiitf|i=i
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" f 1 * sl^i'I 3pll|||s|STRUCTION WHETHER SPECIFIED HEREIN OR NOT I ALSKEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL. LEXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SGRANTING OF THIS PERMITOH
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IBS?E CAREFULLY EXAMINED THE COMPLETED APPLICAIFY UNDER PENALTY OF PERJURY THAT ALL INFOARATIONS ARE TRUE AND CORRECT AND 1 FURTHER=D TO COMPLY WITH ALL CITY COUNTY AND STATETION AND PERMIRMATION HERECCERTIFY AND AG: LAWS GOVF.RNZ 3J z
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z 03 m -<ExpiraticCode shalauthorizedpermit orabandoneen Every permit issued by the Builcexpire by limitation and becomeby such permit is not commence<if the building or work author)at any time after the work is contng Official under the provisions of thisnull and void If the building or workJ within 180 days from the date o< suchzed by such permit is suspended ornmenced for a period of 180 days* AN OSHA PERMiT IS REQUIRED5 0 DEEP AND DEMOLITION OfSTRUCTURES OVER 3 STORIESFOR EXCAVATONS OVER1 CONSTRUCTION OFN HEIGHTm
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CONTRACTOR
1 hereby affirm tnat I am exempt from the Contractor s License Law tor the following reason (Sec , 7031 5Business and Professions Code Any cily or county which requires a permit to construct alter improve demolish orrepair any structure prior to its issuance also requires 'he applicant for such permit to file a signed statement that he islicensed pursuant to the provisions of the Oor-tractor sLicense Law (Chapter 9 commencing with Section 7000 ofDivision 3 of the Business and Professions Code) or that is exempi therefrom and the basis lor the alleged exemption Anyviolation of Section 703i 5 by an applicant lor a permit subjects the applicant to a civil penalty of not more than live nundred dollars ($500)1DESCRIPTION OF WORKP/zcviDf Qt/H* t£&~&t-r%j<~ i-*ri£~f ry &XT&V&&VDESIGNER S ADDRESS1 DESIGNER S PHONE |Q00|^^'-|^7/ S3 |p0D|P/Vor to/H/ Wn/eK Machine CertifiedOWNER S MAILiNG ADDRESSte&l O^-'^i ft(S<? jt#£tf>3rOO <#, ?ZO?#O(Tl
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\[3 1 hereby affirm that 1 am licensed under-provisions of Chapter 9 (commencing withSection 7000) of Division 3 of the Businessand Professions Code and my license is infull force and effectlie Nn ruv,^C ^BLOCKSUBDI VISION7JS ^-^ASSESSOR PARCEL NOTiy4-4^i-/4-o<2CONTRACTOR/-V, , . , f.^-/7 ^o
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D CARLSBAD BUILDING DEPARTMENT APPLICATION & PEP1200 Elm Carlsbad California 92008 1989 (619)4385525H
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