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HomeMy WebLinkAbout2627 OCEAN ST; A; VARIOUS; PermitLICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provi- sions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profes- sions Code, and my license is in full force and ef- fect. OWNER-BUILDER DECLARATION • t hereby affirm that \ am exempt from the Con- tractor's License Law for the following reason (Sec. 7031.5 Business and Professions Code), Any city or county which requires a permit to con- struct, alter, improve, demolish, or repair any structure, prior to its issuance also requires the applicant for such permit to file a signed state- ment that he is licensed pursuant to the provi- sions of the Contractor's License Law (Chapter 9 commencing with Section 7000 of Division 3 of the Business and Professions Code) or that is ex- empt therefrom and the basis for the alleged ex- emption. Any violation of Section 7031.5 by an ap- plicant for a permit subjects the applicant to a civil penalty ot not more than five hundred dollars ($500). Cl, 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 of- fered for sale (Sec. 7044, Business and Profes- sions 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 of- fered for sale. If, however, the building or improve- ment 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 sate). Ill, as owner of the property, am exclusively con- tracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not ap- ply to an owner of property ."ho builds or im- proves thereon, and who contracts for such pro- jects with a contractor(s) license pursuant to the contractor's License Law), I am exempt under Sec. , B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of con- sent to self-insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Labor Code). POLICY NO COMPANY • Copy is filed with the city. • Certified copy is hereby furnished. X CERTIFICATE OF EXEMPTION FROM ORKERS' COMPENSATION INSURANCE {This sectton need not be completed if the per- mit is for one hundred dollars ($100) or less). I certify that in the performance of the work for which thi^permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. NOTICE T9 APPLICANT; If, after making this Cer- tificate of Exef^^ption, you should become subject to the Workers' Compensation provisions of the Labor 0049, you must forth withcoDiply with such provisions or thL^^rmij^fi^bejIleuied rgvoked. CONSTRUCTIONtOHPlNG AGENCY I hereby Wfirm that there is a construction len- ding agency for the performance of the work for which this permit is issued (Sec. 3097, Civil Code). USE BALL POINT PEN ONLY CITY OF CARLSBAD-BUIL.DING DEPARTMENT APPLICATION & PERMiT 1200 ELM AVENUE (714) 438-5525 APPLICANT TO FILL IN INFOR MATION WITHIN RED LINES. NO. V JOB ADDRESS AV. ST. DATE OF APPLICATION OWNER / I OWNER'k PHONE PRIME CONTRACTOR ' ' . OWNER y y. , OWNER'S MAILING ADDRESS ' ' SUBDIVISION ASSESSOR'S PARCEL NO. I I I lllll L DESCRIPTION OF WftBK . , • ^ N V i ^ CONTRACTOR'S ADDREJ5 » STATE LICENSE CONTRACTOR'S ONE DESISNER'S ADDRESS BUS. LICENSE STATE LICEiiSE DESIONEB'S PHONE PERMIT NUMBER I HAVE CAREFULLY EXAMINED THE COMPLETED "APPLICATION AND PERMIT, AND DO HEREBY CERTIFY THAT ALL INFORMATION HEREON IS TRUE AND CORRECT AND I FURTHER CERTIFY AND AGREE IF A PERMIT IS ISSUEO;TO COMPLY WITH ALL CITY, COUNTY AND STATE LAV«S GOVERNING BUILDING CONSTRUCTION, WHETHER SPECIFIED HEREIN OR NOT. I. ALSO AG REE TO SAVE INDEMNIFY AND KEEP HARM- LESS 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. •AN OSHA PERMIT IS REQUIRED FOR EXCAVATIONS 5'-0" DEEP AND DEMOLITION OR CONSTRUCTION STRUCTURES OVER 3 STORIES IN HEIGHT JSOVER— n OWNERn CONTRACTOR AGENT • BY PHONE • l^ DRK APPROVED BY SITE ADDRESS: OWNER: PERMIT NO: ' • FIELD INSPECTION RECORD INSPECTION DATE INSPECTOR WOOD FLOOR FOUNDATION* FORMS • SET BACK •TOILET UNDER FLOOR PLUMBING UNDER FLOOR HEATING OK TO INSTALL SUB FLOOR SLAB FLOOR UNDER SLAB PLUMBING FOOTING • FORMS• SETBACK • TOILET OK TO POUR CONCRETE FRAME ROUGH ELECTRICAL ROUGH PLUMBING ROUGH HEATING/VENTILATING FRAME OK • PLACE INSULATION INSULATION OK • PLACE WALLBOARD WALLBOARD OK. PLAGE TAPE EXTERIOR LATH OK • PLACE STUCCO FIREPLACE DAMPER 8tSTEEL PLATE TIES/HEIGHT OF CHIMNEY OTHER TEMP POWER (POLE) SEWER GAS TEST SWiM POOL • STEEL BONDING • PRE DECK • FENCE PREPLASTER SHOWN • FRAME • PAN FINAL INSP BY BLDG DEPT OTHER DEPT'S REQ COMPLETED ELEC METER-PERM-TEMP GAS METER-PERM-TEMP CERT OF OCCUPANCY ISSUED INSPECTOR'S NOTES LICENSED CONTRACTOR'S DECLARATION I hereby affirm that t am licensed under provi- sions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profes- sions Code, and my license is in full force and ef- fect. ^ OWNER-BUILDER DECLARATION Dl hereby affirm that I am exempt from the Con- tractor's License Law for the following reason (Sec. 7031.5 Business and Professions Code), Any city or county which requires a permit to con- struct, alter, improve, demolish, or repair any structure, prior to its issuance also requires the applicant for such permit to file a signed state- ment that he is licensed pursuant to the provi- sions of the Contractor's License Law (Chapter 9 commencing with Section 7000 of Division 3 of the Business and Professions Code) or that is ex- empt therefrom and the basis for the alleged ex- emption. Any violation of Section 7031.5 by an ap- plicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). • 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 of- fered for sale (Sec. 7044, Business and Profes- sions 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 of- fered for sale. If, however, the building or improve- ment is sold wtthin 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). • I, as owner of the property, am exclusively con- tracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not ap- ply to an owner of property .•ho builds or im- proves thereon, and who contracts for such pro- jects with a contractor(s) license pursuant to the contractor's License Law). I am exempt under Sec. , B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of con- sent to self-insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Labor Code). POLICY NO. COMPANY • Copy is filed with the city. • Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the per- mit is for one hundred dollars ($100) or less). I certify that in the performance of the work for which thie permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. NOTICE TO APPLICANT: If, after making this Cer- tificate of Exe»T\ption, you shouid become subject to the Workers' Compensation provisions of the Labor cAle, you must forthwith comply with such pr^sions^thi^lgrmU sh^be^eemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction len- ding agency for the performance of the work for which this permit is issued (Sec. 3097, Civii Code). USE BALL POINT PEN ONLY CITY OF CARUSBAD-BUIUDING DEPARTMENT APPLICATION & PERMIT 1200 ELM AVENUE (714) 438-5525 APPLICANT TO FILL IN INFOR MATION WITHIN RED LINES. Wigii^iniyi iCi^iftiVifn4i t I i^juixili iOir-igitviA/i JOB ADDRESS OWNER'S PHONE OWNER'S MAILINO ADDRESS RD l/^lV lg I L_i_ DATE OF APPLICATION PRIME CONTRACTOR Wc-Tte.v«;_ CONTRACTOR'S ADDRESS SUBDIVISION ASSESSOR'S PARCEL NO. I I I llllll L_J DESCRIPTION OF WORK ^ CENSUS TRACT GP LAND U S^ / ZONINS BLDG SO. FT. QTY BUS. LICENSE STATE LICENSE PLUMBING PERMIT EACH FIXTURE TRAP EACH BUILOING SEWER EACH WATER HEATER AND/OR VENT EACH GAS SYSTEM 1 TO 4 OUTLETS EACH GAS SYSTEM 5 OR MORE EACH INSTAL., ALTER, REPAIR WATER PIPE EACH LAWN SPRINKLER SYSTEM WATER SOFTNER TOTAL PLUMBING CONTRACTOR QTY, ELECTRICAL PERMIT NEW CONST EA AMP/SWT/BKR Pf*^^ 1 PH .25 3PH EXIST BLDG EA AMP/SWT/BKR 1 PH .25 3PH REMODEL/ALTER PER CIRCUIT TEMP POLE 200 AMPS OVER 200 AMPS TEMP OCCUPANCY (30 DAYS) TOTAL ELECTRICAL CONTRACTOR CONTRACTOR'S PHONE STATE LICENSE DESIGNER'S PHONE UMBER OF STORIES PERMIT NUMBER my\ 35' ii/S: /g i Not Valid Unless Machine Certified 8? < Q BUILDING PERMIT SIGN PERMIT PLAN CHECK ALL INCLUSIVE PERMIT TOTAL PLUMBING ELECTRICAL MECHANICAL MOBILE HOME SOLAR MICO-FILM TOTAL FEES PAYABLE I HAVE CAREFULLY EXAMINED THE COMPLETED ••APPLICATION AND PERMIT, AND DO HEREBY CERTIFY THAT ALL INFORMATION HEREON IS TRUE AND CORRECT AND I FURTHERCERTIFYANDAGREEIFAPERMITIS ISSUED; TO COMPLY WITH ALL CITY, COUIVTY AMD STATE LAWS GOVERNING BUILDING CONSTRUCTION, WHETHER SPECIFIED HEREIN OR NOT. I. ALSO AGREE TO SAVE INDEMNIFY AND KEEP HARM- LESS 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. •AN OSHA PERMIT IS REQUIRED FOR EXCAVATIONS 5^-0" DEEP AND DEMOLITION OR CONSTRUCTION OF STRUCTURES OVER 3 STORIES IN HEIGHT -Ul 7^ a. Ul APPLICANT^SlSlGNATURE OWNERQ CONTRACTO AGENT • BY PHONlE APPROVED BY SITE ADDRESS: OWNER: J^ERMlt NO: FIELD INSPECTION RECORD INSPECTION DATE INSPECTOR WOOD FLOOR FOUNDATION • FORMS • SET BACK 'TOILET UNDER FLOOR PLUMBING UNDER FLOOR HEATING . OK TO INSTALL SUB FLOOR SLAB FLOOR UNDER SLAB PLUMBING FOOTING • FORMS • SETBACK » TOILET OK TO POUR CONCRETE FRAME ROUGH ELECTRICAL ROUGH PLUMBING ROUGH HEATING/VENTILATING FRAME OK • PLACE INSULATION INSULATION OK • PLACE WALLBOARD WALLBOARD OK . PLACE TAPE EXTERIOR LATH OK* PLACE STUCCO FIREPLACE DAMPER & STEEL PLATE TIES/HEIGHT OF CHIMNEY OTHER TEMP POWER (POLE) SEWER GAS TEST SWIM POOL • STEEL BONDING • PRE DECK • FENCE PREPLASTER SHOWN • FRAME • PAN FINAL INSP BY BLDG DEPT OTHER DEPT'S REQ COMPLETED •ILEC METER-PERM-TEMP ;ASMETER-PERM-TEMP ;ERT OF OCCUPANCY ISSUED INSPECTOR'S NOTES z o < cc < -J o Ui a < flC z r o a £ UJ z o z g < Z UJ a. S o o cc O o Z r~l I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lie No Class i hereby atfirm that I am exempt trom Ihe Conlrac- tor s License Law tor tlie fotlowing reason (Sec. 7031.5 Business and Professions Code: Any city or county which re- quires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also requires the ap- plicant tor such permit to tile a signed statement that he is Iicensed pursuant to the provisions of Ihe Contractor s License Law (Chapter 9 commencing with Section 7000 of Division 3 of the Business and Prolessions Code) or that is ex-empt therefrom and the basis tor the allegeo exemption Any violation of Section 7031.5 by an applicanl tor a permit sub- jects the applicant to a civil penalty of not more than live hun- dred dollars ($500). I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the struc- ture is not intended or offered for sale (Sec 7044. Busmess 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 nol intend- ed or offered for sale. If, however, the building or improve- ment is sold within one year ot completton, the owner-builder will have the burden of proving that he did not build or im- prove for the purpose of sale). m I, as owner o( the properly, am exclusively contracting with licensed contractors to construct the projecl (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or im- proves Ihereon, and who contracts tor each projects wilh a contractor(s) license pursuant to the Contractor's License Law). •2 As a homeowner I am improving my home, and the (oIlow mg conditions exist: 1. The work is being perlormed prior to sale 2. I have lived in my home for twelve months prior to completion of this work. 3. I have not claimed this exemption during the last three years. B&P C. C I am exempt under Sec. for itiis reason • I tiereby atfirm that I have a certificate ot consenl to self insure, or a certificate of Workers Compensation Insurance, or a cenifieO copy thereof (Sec 3800. Labor Codei POLICY NO COMPANY Copy IS filed witti the city Q Ceditied copy is hereby furnished CEf^TlFICATt OF EXEMPTION FROM WORKERS COMPENSATION INSURANCF (This section need not be completed if the permit IS toi one hundred dollars ($100) or lessi • I cerlity that in the performance of lhe *orV lor which this permit is issued, I shall not employ any person in any manner so as to become subject lo tbe Wor>(ers' Compensation Laws of California NOTICE TO APPLICANT If, after making this Cerli ficate of Exemptton. you should become subject lo the WorVers' Compensation provisions of Ihe Latx)r Ccxle, you must forthwith comply with such provisions or this permit shalt be deemed revoked Q I hereby affirm tnsf there is a conslruclion lending agency 'or the pfertoimance ot lhe work toi which this permit is issued iSec 3097 Civil Codei Lender s Name Lender s Address , USE BALL POINT PEN ONLY & PRESS HARD APPLICANT TO FILL IN INFORMATION WITHIN SHADED AREA AND DECLARATIONS. ^(^?hr..//^ TiQ CARLSBAD BUILDING DEPARTMENT 1200 Elm, Carlsbad, California 92008-1989 (619) 438-5525 APPLICATION & PERMIT JOB ADORESS A V. ST. RD. NEAREST CROSS ST. SUBDIVISION ASSESSOR PARCEL NO. OWNER'S NAME OWNER S PHONE OWNER'S MAILING ADDRESS ^""^ DESCRIPTION OF WORK CENSUS TRACT GP LAND USE PARK ING SPACE RES UNITS OATE OF APPLICATION BUSINESS LICENSE # CONTRACTORS PHONE » 7W^y7r /^/ly CONTRACTOR'S ADDgreSS _ LICENSE NO. DESIGNER DESIGNER S ADDRESS F/P FLR ELEV. GRADING PERMIT ISSUED y • N • REDEVELOPMENT AREA NO STORIES TYPE CONST DESIGNER'S PHONE EDU FIRE SPR VALUATION PLAN I.D. # STANDARD PLAN # PERMIT NUMBER BLDG USE CODE BUILDING SQ. FOOTAGE Nor Valirl Unless Uac/iine Certifierl QTY. PLUMBING PERMIT - ISSUE 7^ QTY. MECHANICAL PERMIT - ISSU E 5— SUMMARY/ACCOUNT NUMBER EACH FIXTURE TRAP / INSTALL FURN. DUCTS UP TO 100,000 BTU BUILDING PERMIT 01-00-00-8220 EACH BUILDING SEWER OVER 100,000 BTU SIGN PERMIT 01-00-00-8221 EACH WATER HEATER AND OR VENT BOI LER/COMPRESSOR UP TO 3 HP PLAN CHECK 01-00-00-8806 •• iiflC' —" EACH GAS SYSTEM 1 \ Q ^ OUTLETS BOILER/COMPRESSOR 3 15 HP TOTAL PLUMBING 01-00-00-8222 EACHGASSYSTEMbORMORE 1 METAL FIREPLACE ELECTRICAL 01-00-00-8223 EACH INSTAl. , ALTER, REPAIR WATER PIPE VENT FAN SINGLE DUCT MECHANICAL 01-00-00-8224 EACH VACUUM BREAKER MECH EXHAUST HOOD DUCTS MOBILEHOME 01-00-00-8225 WATER SOFTNER RELOCATION OF EA FURNACE/HEATER MOBILEHOME PARK INSP EACH ROOF DRAIN CNS'DE SOLAR 0.1-00-00-8226_.. TOTAL MECHANICAL STRONG MOTION 80-92-33-0519 TOIAl PLUMBINL FlRESPRINKLERS 01-00-00-8227 QTY. ELECTRICAL PERMIT - ISSUE ^— QTY. SOLAR - ISSUE PUBLIC FACILITIES FEE 32-00-00-8930 QTY. ELECTRICAL PERMIT - ISSUE ^— QTY. SOLAR - ISSUE BRIDGE FEE NEW CONST EA AMP SWT BKR COLLECTORS SCHOOL FEE - DISTRICT 1 PH 3 PH STORAGE TANKS Carlsbad 80-92-21 -0519 EXIST BLDG EA AMP SWT BKR ROCK STORAGE Encinitas 80-92-22-0519 1 PH 3 PH PUMP San Dieguito 80-92-23-0519 REMODEL ALTER PER CIRCUIT PIAN CHECK FEE San Marcos 80-92-24-0519 TEMP POLE 200 AMPS OVER 200 AMPS LICENSE TAX 01-00-00-8162 TEMP OCCUPANCY 130 DAYS) MFF 80-92-57-0519 CREDIT DEPOSIT TOTAL ELECTRICAL i i J i TOTAL SOLAR TOTAL FEES PAYABLE I HAVE CAFiEFULtY EXAMINED THE COMPLETED t'APPLICATION AN0 PERWIT".:ANBOO HEREBY CERTIiY UNDER ,PEN<iL-TY,OF PERJURY THAT SLL INFORMATION HEREOlsHNGtUBlNQ, THE tfECfcXftATIONS'AHE TRUE AND CORRECT AMB1 raRTHte:CERTlFY *ND ACREE IFPERMIT IS=" ISSUEO: TO €©MPLY WITH ALL CltY,.COUMjy AND STATE LAWS GOVERNING BUILDING CON- STRUCTION. WHETHER SPECIFIED HERilN OR NOT, I ALSO AGREE TO SAVE INDEMNIFY AND^ HEE.P HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABIUTIES. JUDGMENTS, COSTS EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE Of petmit ng Official under tlie provisiehsof this null and void. If tfie bmiding orworti wtthin JSOdays }fom ItVe dateot such by such permit Is suspended or eomgl^nced tor a period of 180 days. OWNER • CONTHACTOl BY PHONE • * AN OSHA PERMIT ^ nEQUlMO FOR EXCAVATIONS OVEA 5 0 • OEEJ' ANO DBilOtfTION 0« CONST«UCT|0*l Of STROCTWiiS OVER 3 STORIES IN HEKSHT APPRO>«D BY DATE I ly^^ 1 TYPE , DATE INSPECTOR BUILDING \ FOUNDATION i REINFORCED STEEL I MASONRY 1 GUNITE OR GROUT | FLOOR & CEILING SUB FRAME i SHEATHING • ROOF • SH^AR FRAME 1 EXTERIOR LATH \ INSULATION 1 INTERIOR LATH & DRYWALL ; 1 PLUMBING ; SEWER AND BUCO DIPUCO i UNDERGROUND • WASTE • V/ATER TOP OUT • WASTE • WATER TUB AND SHOWER PAN | GAS TEST 1 • WATER HEATER • SOLAR WA)"ER ELECTRICAL \ • ELECTRIC UNDERGROUND • IDFFER ROUGH ELECTRIC [ • ELECTRIC SERVICE • TEMPORARY • BONDING • POOL \ 1 MECHANICAL • DUCT & PLEM., • REF. PIPING HEAT — AIR COND. SYSTEMS \ VENTILATING SYSTEMS i 1 CALL FOR FINAL INSPECTION WHEN ALL APPROPRIATE ITEMS ABOVE HAVE BEEN APPROVED. FINAL ' PLUMBING 1 ELECTRICAL [ MECHANICAL i GAS 1 BUILDING 1 —I——f— ^—- SPECIAL CONDITIONS \ 1 m ' » B FIELD INSPECTION RECORD REQUIRED SPECIAL INSPECTIONS INSPECTOR S NOTES INSPECTION REQ IF CHECKED INSPECTOR S APPROVAL DATE SOILS COMPLlAtslCE PRIOR TO FOUNDATION INSP SOILS COMPLlAtslCE PRIOR TO FOUNDATION INSP STRUCTURAL CONCRETE OVER 2000 PSI PRESTRESSED CONCRETE POST TENSIONED CONCRETE FIELD WELDING HIGH STRENGTH BOLTS SPECIAL MASONRY PILES CAISSONS City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 06-11-2003 Plumbing Permit Permit No: CB031612 Building Inspection Request Line (760) 602-2725 Job Address: 2627 OCEAN ST CBAD St: A Permit Type: PLUM status: ISSUED Parcel No: 2031400700 Lot#: 0 Applied: 06/11/2003 Construction Type: NEW Entered By: RMA Reference #: Construction Type: NEW Plan Approved: 06/11/2003 Issued: 06/11/2003 Project Title: BURCHFIELD RES-NEW H20 HEATER Inspect Area: Applicant: Owner: ARS BURCHFIELD FAMILY TRUST 03-02-92 STE 100 6162 NANCY RIDGE DR 50 N TAMMI CT SAN DIEGO CA 92121 CLOVIS CA 93611 858-677-5455 Plumbing Issue Fee $20.00 Fixture or Trap 0 $0.00 Building Sewer 0 $0.00 Roof Drain 0 $0.00 Install/Repair Water Line 0 $0.00 Water Heater and/or Vent 1 $7.00 Gas Piping System 0 $0.00 Vacuum Breaker 0 $0.00 Other Plumbing Fees $0.00 Master Drainage Fee $0.00 yy Sewer Fee $0.00 Additional Fees $0.00 TOTAL PERMIT FEES $27.00 Total Fees: $27.00 Total Payments To Date: $0.00 Baiar^Cfg Inspector: FINAL APPROVAL Date: ^ -QJ> clearance: NOTICE: Please take |J(2rriCE tK^pproval of your project Includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter collectively referred to as "fees/exactions." Vdu 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 Govemment 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 fees/exactions of which vou have previously been given a NOTICE similar to this, or as to which the statute of limitations has previously othenvise expired. PERMIT APPLICATION CITY OF CARLSBAD BUILDING DEPARTMENT 1635 Faraday Ave., Carlsbad, CA 92008 1. PBOJECl i«r\*n*¥i#*nv/« J. FOR OFFICE USE ONLY PLAN CHECK m.Cl/l /O ? ^ EST. VAL. Plan Ck. Deposit Validated B; Date Address (include BIdg/Sulte #) Business Name (at this address) Legal Description Lot No. bdivlsion Name/Number Unit No. Phase No. Total ft of units Assessor's Parcel # Existing Use Proposed Use Description of Work \ , N » • A 1 SQ. FT. 2 CONTACT PERSON (If dlffaranl from applicant) #of Stories ft of Bedrooms # of Bathrooms Name 3 . APSLICANT n Contractor ^SiSgent for Contractor • OAner • Ageat for Oviinar , / gan^ Address J O City State/Zip Telephone # / J Address City State/Zip Telephone ft / City State/Zip Telephone tt Fax tt Name B CONTRACTOR • COMPANY NAME (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, 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 exejQptitin. Any violation of Section 7031.5 by any applicant for a perrnit subjects the applicant to a civil penalty of not more than five hundred dollars [$5001). [Chapter a, commending with section /uuu or uivision a or tne Business ano rroressions i.,oaej or inai ne is exempt inerorrom, ana ine exemption. Any violation of Sectipn 7031.5 by any applicant for a perrnit subjects the applicant to a civil penalty of not more than five hundre Name r—• ^ i ^ J Address O y.^ _ i '-'•V State/Zip Telephi Name n rv i ^ ^ _^ ^Aooress \j ^ ^_ /^O/ ""'^^ oxaie/i.ip Telephone* State License tt | " j Ss «=^Q License Class C ^i^-Dj ^ 7)ko City Business License # I 0 OTI Designer Name Address City State/Zip Telephone State License tt 6. WORKERS' COMPENSATION Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations: Q 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. 'P'^ 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. IVIy worker's ^f(npensatipp insuranc^carrier and policy number are: Insurance Company Policy No, Expiration Date_ (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS [$1001 OR LESS) Q 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' Compensation Laws of California. WARNINQ: Failure to secure worlcers' compensation coverage is unlawful, and shall subject an employer to criminai penalties and civil fines up to one hundred thousand dollars ($300,00&), in addition to the CMt of compensation, damages as provided for in Section 3706 of the Laboc code, Jnterest and attomey's fees. SIGNATURE VAAO<-Zv>*-g(l^''^. 0_(jv-.A'''-'r^ DATE Lo U I tor's LicensVLaw I hereby affirm that I am exempt from the Contractor's LicensVlaw for the following reason: Q 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). Q 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: 1. I personally plan to provide the major labor and materiais for construction of the proposed property improvement. Q YES QNO 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 / 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 (Include name / address / phone number / contractors license number): 5. I will provide some of the work, but I have contracted (hired) the following persons to provide the work indicated (Include name / address / phone number / type of work): PROPERTY OWNER SIGNATURE DATE COMPLETE THIS SECTION FOR N0N-RESID£NT1AL BUILDING PERMITS 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? • VES • NO Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? Q YES Q NO Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? • YES • 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 , > I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097(i) Civil Code). LENDER'S NAME LENDER'S ADDRESS 9. ' APPLICANT CERTinCATtON " ' , ' , ' . ' C * , =^ I 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 agree to comply with all City ordinances and State laws relating to building construction. I hereby authorize representatives of the CitV of Carlsbad to enter upon the above mentioned property for inspection purposes. 1 ALSO AGREE TO SAVE, INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABIUTIES, 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 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 limitation 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 Js suspended or abandoned at any time fter the work is commented for a Dgriod of 180 days (Section 106.4.4 Uniform Building Code). , APPLICAN SIGNATURE ^-J\. (Jr-*^^^ \^ ^'^'^^ li? WHITE^File YELLOW: Applicant PINK: Finance T JNSCHEPULED BUILDING INSPECTION riATV fn^^-i^n:^ INSPECTOR ^ PERMIT #J22ALfA:^ PLAN CHECK # JOB Anr)T^F.S!<^ "^^f-^^ /Or/^r.^ DESCRIPTION ^'^/r CODE DESCRIPTION ACT COMMENTS 5