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Home My WebLink About2405 JACARANDA AVE; MULTI-PERMIT FILE; CB120965; PermitCity of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 Plumbing/Mechanical/Electrical (PME) Permit 05-23-2012 Permit No: CB120965 Building Inspection Request Line (760) 602-2725 Job Address: Pem,it Type: 2405 JACARANDA AV CBAD PME Status: Parcel No: 2550702900 Lot#: 0 Applied: ISSUED 05/23/2012 LSM 05/23/2012 05/23/2012 Reference#: PC#: Project Title: HERMANN RES -REPLACE WTR HTR Applicant: CALIFORNIA DEL TA MECHANICAL SUITE# 27 12440 OAK KNOLL RD 92064 866-898-0008 Plumbing Fees Electrical Fees Mechanical Fees Other PME Fees TOTAL PERMIT FEES Entered By: Plan Approved: Issued: Inspect Area: Owner: BELLO BERNARD&TERESA D 2405 JACARANDA AVE CARLSBAD CA 92009 $30.00 $0.00 $0.00 $65.00 $95.00 Total Fees: $95.00 Total Payments To Date: $95.00 Balance Due: Inspector: y11, .. ~" Clearance: _____ _ $0.00 NOTICE: Please take NOTICE that approval of your project includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter collectively referred to as "fees/exactions." You have 90 days from the date this permit was issued to protest imposition of these fees/exactions. If you protest them, you must follow the protest procedures set forth in Government Code Section 66020(a), and file the protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section 3.32.030. Failure to timely follow that procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their imposition. You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection fees and capacity changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this project. NOR DOES IT APPLY to any f x i n f whi h v r . . Tl E imil r hi r whi h h i City of Carlsbad f~ Plan Check No. Q-8 r d-O°t &J --.< 1635 Faraday Ave., Carlsbad, CA 92008 Est. Value 760-602-2717 / 2718 / 2719 ~ ~--Yr-' Fax: 760-602-8558 Plan Ck. Deposit ~~:--~ Building Permit Application -?l ;;>-3 I c "t.-Date I JOB ADDRESS SUITE#/SPACE#/UNIT# IAPN 2405 Jacaranda Ave --- CT/PROJECT# I LOT # I PHASE# I # OF UNITS I # BEDROOMS # BATHROOMS I TENANT BUSINESS NAME I CONSTR TYPE I occ. GROUP DESCRIPTION OF WORK: Include Square Feet of A"ected Area(•) Replace existing like for alike water heater EXISTir~G USE l PROPOSED USE I GARAGE (SF) PATIOS (SF) I DECKS (SF) FIREPLACE IAIR CONDITIONING I FIRE SPRINKLERS YESO No□ YES O NoD vEsO NoO CONTACT NAME (If D/froront Fom Appl/cant) California Delta Mechanical APPLICANT NAME Galina Pavlova ADDRESS ADDRESS 6056 East Baseline rd# 155 6056 E Baseline rd# 155 CITY STATE ZIP CITY STATE ZIP Mesa AZ 85206 Mesa AZ 85206 PHONE PHONE IFAX IFAX 480-898-0007 1-480-218-5645 858-361-6495 858-240-6677 EMAIL EMAIL california(@,deltamechanical.com galinap(@,deltamechanical.com PROPERTY OWNER NAME Teresa Hennann CONTRACTOR BUS, NAME California Delta Mechanical ADDRESS ADDRESS 2405 Jacaranda Ave. 6056 East Baseline rd # 155 CITY STATE ZIP CITY STATE ZIP Carlsbad CA 92009 Mesa AZ 85206 PHONE IFAX PHONE IFAX 760-814-7243 480-898-0007 EMAIL EMAIL ARCH/DESIGNER NAME & ADDRESS I STATE LIC. # STATE LIC.# 'CLASS I CITY BUS. LIC 1214281 811114 c-36 (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 to its issuance. also requires the applicant for such permit to file a si~ned statement that he is licensed pursuant to the provisions of the Contractors License Law [Chapter 9, commending with SecMn 7000 of Division 3 of the Bu::m1ess C:UHJ PIUft:lSS!UII~ CuUl:l} UI TI1c:1l lU::l IS t:l1.t:HIIJ,:1l ll1tmjrru111, crnrJ ltlt:l lJ1;tsis rur lllt:l altegt:ltl t:l.J.tH11µl1u11. Any v1olc:1l1u11 ur St:lt,;l1u1 I t03.l.5 L>y l::llly ttµµtu.;c::111l ru1 Gt µt:Hlflll tiUIJJt:Cl~ lit~ dµl,)IH,A'.Jlll lU ~ c1v1I penalty of not more than five hundred dollars {$500)). Workers' Compensalion Declaration I hereby affirm under penalty of pequry one of the following declarations. 0 I have and will maintain a certificate of consent to self-insure for workers' ccmpensat,on as provided by Section 3700 of the Labor Code, for the pertormance of the work for which this permit 1s issued [Z] I have and will maintain workers' compensation, as reQuired bv Section 3700 of the Labor Code. lo, the perfo,mance of the work fo, which this permit 1s issued M; workers' compensation insurance carr'er and policy nuntier are Insurance Co Policy No 1897823 Expiral,on Dale nro,no,, This sect,on need not be ccmpleted it the permit is for one hundred dollars ($100) o, less. [ZJ Certificate of Exemption: I certify lhal in the pertocmance of the work for whK:h this permit is issued, I shall not empby any person in any manner so as to become subject to the WorrP.rs Compensation Laws of California WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subjec1 an employer to criminal penalties and civil fines up to one hundred thousand dollars (&100,000), in addition to the cost of compensation, damages as provided for in Section 37 6 of the Labo code, interest and attorney's fees. , / _g CONTRACTOR SIGNATURE ....;::f";~c.? / ~ I her9by affirm that I am exempt from Contractor's License Law for the following r9&son. 0 I, as O'Mler of the property or my empbyees v,,fh wages as their sole ccmpensation, v,,11 oo lhe work and the slruclure 1s not intended orotfered lo, sale (Sec. 7044. Business and Profess,ons Code The Caitractor's License Law does not appty-to an owner of property who builds or improves thereon, and who does such work himsett or through his own empbyees. provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of ccmpletion, the owner-builder v,,11 have the burden of proving that he cid not build or improve for the purpose of sale). □ □ I. as O'Mlerof the property, am exclusively contracting with icensed contractors lo construct the project (Sec. 7044. Business and Professions Code. The Contractor's License Law does not appty-to en O'Mlerof property who builds or improves lheroon, and contracts for such projecls with contractor(s) licensed pursuant to the Contractors License Law). I am exempt under Section __ Business and Professions Code for this reason: 1 I personalty-plan lo provide the maioc labor and materials for construction of lhe proposed property improvement. 0 Yes 0 No ? I (have I havA nnl) sionen an appicatinn fnr a huilrino permit for flu, p,opn,..rl mrk 3 I have cootracted wth the follov.ing person (firm) to provide the proposed construction (include name address/ phone I contractors' kcense number). 4 I plan lo provide po,tions of the work. but I have hired the folbwing perron lo COO(dinate, supervise and provide the major work (include name/ address/ phone/ contracbrs' icense number) 5. I v,,11 provide some ol the v.ork. but I have contracted (hired) the following perrons lo provide the vlori< indicated (incude name/ adcress /phone/ type of work) Jt5 PROPERTY OWNER SIGNATURE DATE Is the appficant or future bwlding occupant required to submit a business clan, acutely hazardous materials registration form or nsk management Md prevention program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Acoount Al;f/ D Yes 0 No Is the appicant or future building occupant required lo obtain a permit from the air pollution control cl strict or a![..9!!ality management clstricf? 0 Yes O No Is the facility to be constructed within 1,000 feet of the outer bounda,y of a school site? 0 Yes LJNo IF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT. I certify that I have read the application and statethattheaboveinformation is correct and that the information on the plans isacx:urate. I agree to comply with all City ordinances and State laws relating to building construction. I hereby authonze rep-esenlative of the City d Carlsbad lo enler upon the above menlioned property for inspection purposes I ALSO AGREE TO SAVE. INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST All LIABILITIES, JUDGMENTS, COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE GRANTING OF THIS PERMIT OSHA An OSHA perm I s requwed for excavations ova-5'0' deep and demollkm or construdon of sfrucltres over 3 stories in height. EXPIRATION: Every permt issued by lhe Bu1klng OIIK:ial under lhe p-ovoons of ths Code sllal exprn by lmlation and become nul and vod rt the building or mk authonzed by such permrt IS not commenced within 180 days from the date of such permi or 1f the bui!dng or mrk authorized by such perm!· suspended or abandoned at anyti:"ne aflerthemrk is commenced for a iod of 180 ~ (Section 106 4 4 Uniform Buiding Code) ~APPLICANT'SSIGNATURE DATE 5 -{;;?c::? ~~ «~ ~-CITY OF CARLSBAD Unscheduled Building Inspection Building Department 1635 Faraday Avenue Carlsbad CA 92008 760-602-2700 DATE: _D4° l~tl t2. INSPECTOR: -----~,[_C-___ _ PERMIT#: \"2...oq loS: CONTACT: ~4 ~ PHONE#: :":I--R,4.-::,~ ~ JOB ADDRESS: -----"~ ..... ~:::o...,,o,;;os~~~~...-.-""""<!.~ei~.A-~~~.i:::..=~---------- DESCRIPTION: ---------~----ll_.._'.'t:?_~ ........ 4--'---__ _ CODE ~ ,z,~ Bldg Inspection Form DESCRIPTION ACT Le>~. k\o~ . 14-e ,PL t,t-( V..aN ~(::.//4 COMMENTS No~CAl2:z:> ~l£_. ~i> CD<-"( OF' ~{rJAL ~:po,er tt, +-{oi.1.12:-0wt--lG1~ ~~~. Page 1 of 1 Rev. 06/09 City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 01-04-2008 Plumbing Permit Permit No: CB080055 Building Inspection Request Line (760) 602-2725 Job Address: Permit Type: 2805 JACARANDA AV CBAD PLUM Status: Parcel No: 2551032900 Lot#: 0 Applied: ConstNction Type: NEW Entered By: Reference #: Plan Approved: Issued: Project Title: FURNALD RES REPLACE WTR HTR Inspect Area: Applicant: CALIFORNIA DELTA MECHANICAL SUITE#27 12440 OAK KNOLL RD 92064 866-898-0008 Plumbing Issue Fee Fixture or Trap Building Sewer Roof Drain Install/Repair Water Line Water Heater and/or Vent Gas Piping System Vacuum Breaker Other Plumbing Fees Master Drainage Fee Sewer Fee Additional Fees TOT AL PERMIT FEES 0 0 0 0 1 0 0 Owner: FURNALD FAMILY TRUST 01-19-07 2805 JACARANDA AVE CARLSBAD CA 92009 ISSUED 01/04/2008 KG 01/04/2008 01/04/2008 $20.00 $0.00 $0.00 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.00 Total Fees: $27.00 Total Payments To Date: $27.00 Balance Due: Inspector: Date: Clearance: $0.00 NOTICE: Please take NOT! that pproval of your project includes the 'Imposition' of fees, dedications, reservations, or other exactions hereafter collectively referre<i to as "fees/ex:actions.· You have 90 days from the date this permit was issued to protest imposition of these fees/exactions. If you protest them, you must follow the protest proce<iures set forth in Government Code Section 66020(a), and file the protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section 3.32.030. Failure to timely follow !hat procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their imposition. You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exaclions DOES NOT APPLY to water and sewer connection fees and capacity changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this project. NOR DOES IT APPl Y to any • • • I • • • • i PERMIT APPLICATION CITY OF CARLSBAD BUILDING DEPARTMENT 1635 Faraday Ave., Carlsbad CA 92008 2805 Jacaranda Address (include Bldg/Suite#) Business Name {at this address) Legal Description Lot No. Subdivision Name/Number Unit No. Assessor's Parcel # Existing Use Replace standard water heater like for like Description of Work SQ. FT. # of Stories FOR OFFICE USE ONLY £ PLAN CHECK No.Ctfj~6aZ,- EST. VAL. ·? """ Ck Depos~ Validated By ~/ Date ~1/ Phase No. Total # of units Proposed Use # of Bedrooms # of Bathrooms ~~rnm~•r.111~■111M11.1~•c~iii1Mf.~ii~~~§~i~~~i~!~m~~~J~~~~~~i¾7~~~~i~~~imm~~m~m~~~~i!;.::;~m~mmimm~~~~~~!illif:~tmr~~~0i~~~miill~~i~rn1~~:ir;~~;~~~~:m~~rn'.~:L California Delta Mechanical, Inc. 6052 East Baseline rd# 155 Mesa AZ. 85206 (480) 898-0007 (480) 898-0005 Name Address City Stale/Zip Telephone# Fax# :~1;:i:i:-•r!trlil•!~n~~u~~:1•~1i~mF:H~~~rr.:f.~ffillffiW:11~~~IN!lftHi!IDHHH~!m!mPe~i!~!m!mm,im11g~11~~1gr:fu1'*-~~~:-;~j1h~':i::':' Galina Pavlova 6052 E Baseline rd# 155 MESA AZ 85206 480-898-0007 Name Address City State/Zip Telephone# Same as site Carlsbad CA 92009 760-613-7201 Name Address City State/Zip Telephone# flk~~~~~~:-~wq1~~~nnw1~1gm#ti~m;~~mHi;ijHgfu~m'.~E~t~:~~~~~pi~~m~~~~~~~~~~£~m-~~211~fr~;lu~1nngm~U{t3tilinm~~~mm~mm~gmi~f!~!~i~;~m;;~~it~~~.E.~;~tJ;¼1;~tl~Jiim;i~~m~'.~!~~~F!fi!~~~~i!~~fii~~i;::;~-~::i· (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 to 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, oommending 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 pem,it subjed.s Iha applicant to a civil penalty of not more than rive hundred dollars [$5001). California Delta Mechanical, Inc. 2500 S. Power Rd. Suite# 120 Mesa 85209 (480) 898-0007 Name Address City State/Zip Telephone# State License # 811114 License Class C-36 City Business License # 1214281 Designer Name Address City State/Zip Telephone# State License # Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations: D I have and will maintain a certiflGl!e of oonsent to self-inswe for workers· oompensation as provided by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. [!I I have and will maintain worker's compensation, as required by Section 3700 of the labor Code, for the performance of the work for which this permit is issued. My worker's compensation insurance carrier and policy number are: Insurance Company State Compensation Insurance Fund Policy No. 1697823 Expiration Date""0'--'7"-'/0""l"'/0"'8"-------- (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($1D0] OR LESS) D CERTIFICATE OF EXEMPTION: I certify that in the performance of the work for which this permit is issued, I shall 11C1C employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. WARNING: Failure to secure workers' compensation coverage is uiilawfut and shall subject an employer to c,iminal penalllas and chril lines up to one hundred thousand dollars($100,000}. In addition to the cost of compann • , are provided for in Section 3706 of the Labor Coda, Interest and attorney's,__ SIGNATURE Galina Pavlova DATE....:c0.;;;;l/....;;0.;;;;2;..;/0;..;;8'------- ;;~~~~~~~;~-~~;~~~·.:~~i~~::;.~~~~iJ!'.;l;~~~;~;~;~~~~~;~~~1~;~~;1;Hg~g~;~;~H;~;~;~~~~~;i~~~~~~~~;~;~;;~;~~;~~~~~)~~~t~~;~~;j~~~~~~~~;~~;~;;;;;;;;;;;;;;!~;;;;;:;;;;;~;;~;;~;;;~;~;~;i~~~~~~~~~~~~;~~~:;;~!;~;~;:;~'.;;~~;~~:~t~:;~;'.;~;~: I hereby affirm that I am exempt from the Contractor's License Law for the following reason: D I, as owner of the property or my employees with wages as their sole compensation, will d 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 bufden of proving that he did not build or improve for the purpose of sale). D I, as owner of the property, am exclusively contracting with licensed contractors to oonstruct 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 oontractor(s) licensed pursuaol to the Contractor's License Law). D I am exempt under Section ________ Business and Professions Code for this reason: 1. I personally plan to provide the major labor and materials for construction of the proposed property improvement. D YES D NO 2. I (have/have not) signed an application for a building permit for the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction (include name/ address/ phone number I oontractcrs license number): 4. I plan to provide portions of the work. but I haw hired the following person to coordinate, supervise and provide the major work (indude name/ address/ phone number I lontractorslicensenumber): --------------------------------------------- 5. I will provide some of the work, but I have contracted (hired) the following persons to provide the work indicated (indude name I address I phone number I type of work): PROPERTY OWNER SIGNATURE ____________________________ DATE ___________ _ WHITE: File YELLOW: Applicant PINK: Finance City of Carlsbad Bldg Inspection Request For: 01/24/2008 Permit# CB080055 Title: FURNALD RES REPLACE WTR HTR Description: Type: PLUM Sub Type: Job Address: 2805 JACARANDA AV Suite: Lot: 0 Inspector Assignment: w Phone: 7609429605 Location: Inspector: OWNER. FURNALD FAMILY TRUST 01-19-07 Owner: FURNALD FAMILY TRUST 01-19-07 Remarks: Total Time: CD Description 25 Water HeaterNents Comments/Notices/Holds Associated PCRs/CVs Original PC# Inspection History Date Description Act lnsp Comments ---- Requested By: CARL Entered By: CHRISTl~E ... -------------------·· -···--·---·---•-•o,•• ----- City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 12/29/2000 Plumbing Permit Permit No:CB004935 Building Inspection Request Line (760) 602-2725 Job Address: Permit Type: 2805 JACARANDA AV CBAD PLUM Status: ISSUED 12/29/2000 CB 12/29/2000 12/29/2000 Parcel No: 2551032900 Lot#: 0 Applied: Construction Type: NEW Entered By: Reference #: Plan Approved: Issued: Project Title: FURNALD RES/ NEW WATER HEATER Inspect Area: Applicant: A&J FOSTER, INC. STEB 13706 HWY 8 BUS EL CAJON CA 92021 619-390-4477 Total Fees: $27.00 Plumbing Issue Fee Fixture or Trap Building Sewer Roof Drain Install/Repair Water Line Water Heater and/or Vent Gas Piping System Vacuum Breaker Other Plumbing Fees Master Drainage Fee Sewer Fee TOTAL PERMIT FEES Inspector: Owner: FURNALD CARL F&LYNETTE:ftt;,;; _'.?/ 2805 JACARANDA AVE CARLSBAD CA 92009 Total Payments To Date: $0.00 0 0 0 0 1 0 0 Balance Due: $20.00 $0.00 $0.00 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 ·:_-:1 •. ·; ,!· $27.00 EXPIRED·PERMIT r-· ., ~'' ··: -~-~RED INOORDANCE WITH U.B.C. . ._i; __ CoJ ~ l c2 1 SIGNATURE..c:,!.u,,\ FINAL APPROVAL Date: _____ _ Clearance: NOTICE: Please take NOTICE that approval of your project includes the 'Imposition" of fees, dedications, reservations, or other exactions hereafter collectively referred to as 'fees/exactions.• You have 90 days from the date this permit was issue{! to protest imposition of these fees/exactions. If you protest them, you must follow the protest procedures set forth in Government Code Section 66020(a), and file the protest and any other required information with the City Manager for processing in accordance wlth Carlsbad Municipal Code Section 3.32.030. Failure to timely follow that procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their imposition. You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection fees and capactiy changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this project. NOR DOES IT APPLY to any fees/exactions of which vou have oreviouslv been aiven a NOTICE similar to this, or as to which the statute of limitations has oreviouslv otherwlse expired. FOR OFFICE USE ONLY PERMIT APPLICATION PLAN CHECK NO. c.eca4q- CITY OF CARLSBAD BUILDING DEPARTMENT 1635 Faraday Ave., Carlsbad, CA 92008 EST. VAL. _______ _ Plan Ck. Deposit ........ ------ Validated By _ _.C__.{2..__ ___ _ Date /?..-/ ?..-q/tv j. .. I lll!fflllllllliJllllll!IIIIIUllllllllllllllllllmlllllllllllllllllffl 2805 JACARANDA AYE Carlsbad CA 92009 Address (include Bldg/Suite#) Business Name (al this address) Legal Description Lot No. Subdivision Name/Number Unit No. Phase No. Total # of units Assessor's Parcel # Existing Use Proposed Use WATER HEATER REPLACEMENT Description of Work SQ. FT. #of Stories # of Bedrooms # of Bathrooms Sl Name Telephone# Fax# ~•11 IH111IJIR1111 Name Address City State/Zip Telephone# ~A,i;~11!1!11111111l11111111mm11m1111 11111111•1111111 FURNALD.CARL 2805 JACARANDA AVE CARLSBAD C/l 92009 760-942-3452 Name Address City State/Zip Telephone# (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 to 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, commen<ling 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 ($500D. A & J Foster lncoroorated PO Box 2758 El Caion C1' 92021 6193904477 Name Address City State/Zip Telephone# State License# .. 6 .. 3.,.0.._12=.0,._ ____ _ License Class -=c3=6 _______ _ City Business License # 1210836 ST Designer Name Address City State/Zip Telephone Slate Licence# ________ _ 6. WORKERS' COMPENSATION Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations: D I have and will maintain a certificate of consent to self-insure for workers' compensation as provided by Section 3700 of the Labor Code, for the Performance of the work for which this permit is issued. li2I I have and will maintain workers' compensation, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My worker's compensatioo insurance carrier and policy number are: Insurance Company Mid-Centurv Ins. Policy No. A20075651 Expiration Date 05/01/2001 (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS [$100] OR LESS) D CERTIFICATE OF EXEMPTION: I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the Workers' Comp-alion Laws of C81ifomia. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and Civil fines up to one hundred thousand dollars {$100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor code, interest and attorney's fees. SIGNATURE ~-DATE _1_2_/2_7_/2_00_0 ____ _ 7, OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: D 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). D I, as owner of the property, am exdusively 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 threreon, and contracts for such projects with contractor(s) licensed !!!!..rsuant to the Contractor's License Law). LI I am exempt under Section ______ Business and Professions Code for this reason: 1. 2. I personally plan to provide the major labor and materials for construction of the proposed property improvement. I (have I have not) signed an applicant for a building permit for the proposed work. □ YES ONO 3. I have contracted wilh the following person (firm) to provide the proposed conslruction {include name/ address/ phone number I contractors license number): <Name> <Address> <Work Phone> <State License> 4. I plan to provide portions of th" wor1< hut I havP. hirP.11 lhP. fnllowino n,,mon to coordinate, supervise and provide the major work (include name / address / ~ne number I contractors license number) <Name> <Address> <Work Phone> <state License> 5. I will provide some of the work, but J have contracled (hired) the following person to provide the work indicated (Include name/ address/ phone number/ type of work): <Name> <Address> <Work Phone> <Work TvDe> PROPERTY OWNER SIGNATURE DATE 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 lhe Presley-Tanner Hazardous Substance Account Act? D YES D NO Js the applicant or future building ocC1Jpant required to obtain a permit from lhe nir pollution control district or alr quality management district? □YES □No ls the facility to be constructed within 1,000 feet of the outer boundary of school site? DYES D NO IF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3087(i) Civil Code). LENDER'S NAME LENDER'S ADDRESS --1iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii11■• I certify that I have read the application and state that the above information is correct and that the information on Iha plans is aCCtJrate. I agree to comply with all City ordinances and State laws relating to building construction. I hereby authorize representatives of the City of Carlsbad to enter upon the above mentioned property for inspection purposes. I ALSO AGREE TO SAVE, INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGEMENTS, COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE GRANTING OF THIS PERMIT. 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 limilation and become null and void if the building or work authorized by such permit is not commenced within 180 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 106.4.4 Uniform Building Code). APPLICANT'SSIGNATURE ~ DATE 12/27/2000 -~~~~~-------