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FINAL APPROVAL ~
INSP. J) DATE )·~-q
,CLEARANCE ~~~--'"""---1
CITY OF CARLSBAD
2075 Las Palmas Dr., Carlsbad, CA 92009 (619) 438-1161
•
PERMIT APPLICATION
City of Carlsbad Building Department
2075 Las Palms Dr •• carlsbad, CA 92009 (619) 438-1161
I. PERMIJ IYPE
PIAN CHECK NO. tD
ESf.VAL~----------
PLAN CK DEPOSIT ____ ..,..,~--
VAIID. BY..,,..-T'",....,,.......,...,:c-...P.=---
DATE From Llst l (see back) give code of Permit-Type: ____________ _
For Residential Projects Only: From List 2 (see back) give
Code of Structure-Type: ______________________ _
Net Loss/Gain of Dwelling Units
2. PRQJECf INFORMATION
Address "J ~5 7 O
Nearest Cross Street
LEGAL DESCRIPiiaN Lot No. Subd1V1s1on Name/Number Unit No.
• 2 Soils Report D 1 Addressed Envelope
JI/-11-t. -+'Te S
SQ. FT. # OF STORIES
3. WN IACI PEi&JN (I[ dlHerent from apphcant)
NAME (last name first) ADDRESS
CITY
4. APPllCANI UCUN1.t(AL1UK
NAME (last name first)
CITY
STATE ZIP CODE
DAGEN I FORCONIRACIOR
ADDRESS
STATE ZIP CODE
l ,._.J e.,_
# OF BEDROOMS
DAY TELEPHONE
0 OWNER O AGEN I FUR OWNER
DAY TELEPHONE
FOR OFFICE USE ONLY
Phase No.
# OF BA TIIROOMS
5. PltuPiltN oWNffi
NAME (last name first) ,SC,~ ort IFP'r ADDRESS ,;/.J 7 o G,,zee. « d' /
6. ~.5 t'~ STA;E/!.4-ZIP CODE Pt>?l DAY TELEPHONE
NAME (last name first) C,Avt .,(_j j? /.,.,,.,,. ~,'C 4 ADDRESS 3 %' o o 4.)'~), ,?-,/e .,,;J £),e',
CITY~/stf',,,-t:1 STATE {!_,q... ZIPCODE c;,;{c,,og DAYTELEPHONE 7_,2.q t)q(, /
STATE UC. #;?$"'7:?oL UCENSE CI.ASS {!__-3 b CITY BUSINESS UC.# 3r J/ 0,:)
DESIGNER NAME (last name hrst) ADDRESS
CITY STATE ZIP CODE DAY TELEPHONE STATE UC.#
7. WUllkmtS' lDMPENSAliUN
/0
Workers' Compensation Oedarat1on: I hereby afhrm that I have a cert1hcate of consent to self-msure issued by the Director ol lndusrnal
Relations, or a certificate of Workers' Compensation Insurance by an admitted insurer, or an exact copy or duplicate thereof certified
by the Director of the insurer thereof filed with the Building Inspection Department (Section 3800, Lab. C).
SIGNATURE DATE
8. UWNltit-BOIIDEll DFi!LARA:IIDN
Owner-Builder Declaration: I hereby afttnn that I am exempt from ffie Confradofs License Law for the foilowmg reason:
0 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. If1 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 exclusively 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 thereon, and contracts for such projects
with contractor(s) licensed pursuant to the Contractor's License Law).
• I am exempt under Section ________ Business and Professions Code for this reason:
(Sec. 7031.5 Business and Professions Code: Any City or County which requires a permit to construct, alter1 improve1 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, commencing 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 [$500]).
SIGNATURE DATE
COMPLf:iE iAIS S£ciiON FOR NON-RESIDENIIAL B0iilltNG PERMIIS ONLY:
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 the Presley-Tanner Hazardous Substance Account Act? •YES •NO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? • YES • NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? •YES •NO
IF ANY OF TIIEANSWERS ARE YES, A FINAL CERTIFICATE OF oa:IJPANCY MAY NOT BE Il?SI)IID AFTER JULY 1, 1989 UNLESS nm APPLICANT
HAS MET OR IS MEETING TIIE REQUIREMENTS OF TIIE OFFICE OF EMERGENCY SERVICES AND TIIE AIR POU.UTION OONTROL DISl1UCT.
9. WNSIR0CIKJN fiNDING AGENCY
i hereby afhrm that there 1s a construction lendmg agency for ihe performance of the work for which this permit 1s issued (Sec 3097(1) ClVli Code).
LENDER'S NAME LENDER'S ADDRESS
JO. APPIJCAN I CfltlOICAliUN
I certify that I have read the apphcatJOn and state that the above mformat1on 1s correct. I agree to comply with all City ordmances 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 m SAVE INDEMNIFY AND KEEP IIARMLF.SS TIIE CTlY OF CARISBAD AGAINST All. UABILITIF.S, JUDGMENTS, CDSTS
AND EXPENSES WlllOI MAY IN ANY WAY A<XJUJE AGAINST SAID CTlY IN OONSEQIJENCE OF TIIE GRANTING OF TIIIS 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 Ccxle shall expire by limitation and become null and void if the
building or work authorized by such permit is not commenced within 365 days from the date of such permit or if the building or work authorized by
such permit is suspended or aban at any time after work is commenced for a period of 180 days (Section 303(d) Uniform Buj1cjjxlg Code).
APPUCANTS SIGNATURE DATE: ~..:(,£,'1'-
PINK: Finance
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