HomeMy WebLinkAbout2548 LUCIERNAGA ST; ; CB981332; PermitPERMIT APPLICATION
FOR OFFICE USE ONLY
PLAN CHECK NO. ?f.3 (33/./
CITY OF CARLSBAD BUILDING DEPARTMENT
2075 Las Palmas Dr., Carlsbad CA 92009
(760) 438-1161
EST. VAL.-------.,...;,-,..,.....
Plan Ck. Deposit __ _...,r;,,c.,,....k.:::..!.!:." {Jl)
Validated By ____ "'":..!:-;!,,m_.,4,-,,
Dat•--~-------'+-''1-,_;..V
Address (include Bldg/Suite #) Business Name lat this address)
Legal Description Lot No. Subdivision Name/Number Unit No. Phase No. Total # of units
Proposed Use
Description of Work #of Stories # of Bedrooms # of Bathrooms
2. CONTACT PERSON (If dlffeNnt fronr•ppllc■ntJ
Name
3.
4. PROPERTY OWf!ER
/_.ydM L),44#7
Name
&. CONTRACTOR -COMPANY NAME
Address
State/Zip
State/Zip
C 5--" d:7;&,i::,';/' tJii:b?'
Citv S.tate/Zip
",.:.•·" : >•,'••H>',,,,,
Telephone II Fax#
Telephone II
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 ha is licensed pursuam to the provisions of the Contractor's License Law
(Chapter 9, commending 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 viola!,irn of Sectio I rg~1 ,§ by any applicant for a permits bjects t.!)11 ap~~ to a c~enalty of not ore than five hundred dollars 1$500)). 'L ff/. t!£.# I ,iUc ::,.,-::;,., . <:'.. ~M-,
Name ! _· /:~ ~✓ Address • A ✓o City State/Zip Telephone#
State License # _ _.({l_"'-~'tL..r...~~"'--'?:1."----1---License Class __ <..:.-=~'--==----City Business Ucense # _______ _
Designer Name Address City State/Zip Telephone
State License # __________ _
8. WORKERS' COMPENSATION
Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations:
0 t have and will maintain a certificate of consent to self-insure for workers' compensatlon as provided by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued.
D I have and will maintain workers' compensation, as required by Section 3700 o:f 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______________________ Policy No. ____________ _ Expiration Date, _______ _
ION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($100I 0R LESS)
CERTIFICATE OF EXEMPTION: I certify that in the performance of the work for which this permit is issued, I shall not employ any parson In any manner 10 11
to become subject to the orkers' Compensation Laws of California.
WARNING: Failure to sec re w amiatlon coverege i• unlawful, and llhall •ubjttet an employer to crlmlnal penattJa1
thousand dollar• ($1 ,0 0), in a cost of compensation, damage• •• provided for in Section 3706 of the Labo ode
SIGNATURE _ _L1,:~~':.!'.:-'&;,,::;~~C:::>:-----------------DATE
7. OWNER-BUILDER DECLARATION
I hereby affirm that I am exem'pt from the Contractor's License Law for the followlng 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
(Sac. 7044, Business and Professions Code: The Contractor's License Law does not apply to en ownar of property who builds or Improves thereon, and who don
such work himself or through his own employees, provided that such improvements·are not intended or offered for s■le. tf, 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).
O I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and ProfHsions 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 contractor(s) licensed
pursuant to the Contractor's License Law). ·
0 I am exempt under Section ______ Business and Professions Code for this reason:
1. I personally plan to provide the major tabor and materials for construction of the proposed property improvement. D YES ONO
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 numb.er I contractors license number):
4. I plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work Hnclude name I address/ phone number I contractors license number): ________________________________________________ _
5. I will provide some of the work, but I have contracted (hired) the following parsons to provide the work Indicated !include name / address / phone number / type of work): ______________________________________________________ _
PROPERTY OWNER SIGNATURE_______________________ DATE _________ _
COMPLETE THIS SECTION FOR fJO/i.RESIDENTIAJ.· BUILPINB'·PlRMtTS C>Nl::Y:"i"1.:._: i: .·~.: .~;J:::', .;,.:,/t,/1 .. ~-·,;;
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 26606, 25533 or 25634 of the Presley-Tanner Ha:rardous Substance Account Act? D YES O NO
Js the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? 0 YES D NO
Is the facility to be constructed within 1,000 feat of the outer boundary of a school site7 0 YES O 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.
8. CONSTRUCTION LENDING AGENCY ,,, · <,,.,,:,:, :., ,
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 309710 Civil CodeJ.
LENDER'S NAME _____________ _ LENOER'S ADDRESS ______________________ _
9. APPLICANT CERTIFICATION >.-::. : •. ~,f\•i ;;'.'.',.?' +, .. •:,'. '.,. ,,.:3 ,(·;Vt:C::1
1 certify that I have read the application and state that the above Information is correct and that the information on the plans is accurate. I agr8e to comply with all
City ordinances and State laws relating to building construction. I hereby authorize representatives of the Cltt' 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,
JUDGMENTS, 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 6'0" deep and demolition or construction of structures over 3 stories in height.
EXPIRATION: Every permit issued by
work authorized by such permit is n
or abandoned at any time after the
APPLICANT'S SIGNATURE
e Building Official under the provisions of this Code shall expire by llmltation and become null and void if the building or
mmen<i,Q,,d with' 365 ys from e date of such permit or if the building or work authorized by uch permit is suspended
· or a od of days !Section 108.4.4 Uniform Building Code).
~ OATE
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