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CITY OF CARLSBAD
2075 Las Palmas Dr., Carlsbad, CA 92009 (619) 438-l 161
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PERMIT APPLICATION ~ V
PLAN CHECK NO.
City of carlsbad Building Oepartaent
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~V~ DEPOSIT _______ _
2075 Las Pal•• Dr., carlsbad, CA 92009 (619) 438-1161
VAIID. BY __________ _
I. PmlMli JiPE DATE
A -U COmmerctal O New Budd mg U I enant Improvement
B -D Industrial □ New Building □ Tenant Improvement
C -Jl Residential D Apartment □ Condo □ Single Family Dwelling □ Addition/ A1teration
C Duplex □ Demolition □ Relocation □ Mobile Home W Electrical □ Plumbing
iMechanical □ Pool □ Spa □ Retaining Wall □ Solar □ Other
2. PROJF.Cf INFORMATION FOR OFFICE USE ONLY
~~ 1-1,-,J/Jllvl)
Nearest Cross Streer
BuUdmg or Smte No.
LEGAL DESCRIVIION Lot No. Sutxi.1V1s1on Name/Number Omt No. Phase No.
/,
CHECK B£WW IF S0BMI 11 £0:
□ 2 Energy Cales □ 2 Structural Cales □ 2 Soils Report □ l Addressed Envelope
ASSESSOR'S PARCEL EXISTING USE PROPOSED USE
'
DESCRIPTION OF wo2,. ...J. ,_ ..,AA ,,. _ _,,. . "'"',-,.,;, ser. ~c. "' -"<.J ..,,.,r-. .:1, :Z:,.,$1,tll I 50 -,o Zyo Vcll-J#c.-/ ( lie:;-/. t:/M,t111,
.3 t..t.,~ )I IV, ~ 3'/z. Tt>u SQ. IT. # OF STORIES
1 eren rom app 1can
NAME ADDRESS
CI1Y STA TE ZIP CODE DAY TELEPHONE
4. N'YLllANt ~NIRACIOk □AGENi FORWNIRACIOR DOWNER UAGENI FOR OWNER
NAME w ,-11;...,..""-~. co'°'"'"~ ADDREss
STATE CA: ZIP CODE 9go('.)7 DAY TELEPHONE
STATE HONE
1-z..q+ t ~~ t-
sTATE ZIP CODE DAY TELEPHONE
ADDRESS
DESIGNER NAME
STATE UC. # 'ff, f qr,qUCENSE CLASS CI1Y BUSINESS UC.#
ADDRESS
CI1Y STATE ZIP CODE DAY TELEPHONE STATE UC.#
7. WOltkERS' WMPENSAIIUN
Workers' Compensation Deciarat1on: I hereby afurm that I have a cert1hcate of consent to self •msure issued by the b1rector of Industnal
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).
INSURANCE COMPANY IV-4. POUCYNO. EXPIRATION DATE
Ceruhcafe of Exemption: I certify that m the performance of the work for which this pemuf 1s issued, I shall not employ any person m any manner
so as to become subject to th Workers' Compensation Laws of California.
I hereby affmn that I am exempt from the Contracto?s Llcense Law for the followmg 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 Llcense 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 exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's Ucense 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.S Business and Professions Code: Any City or County which requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its i~uance, 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
COMPLEIE IHIS SECilON FOR NON-RESIDEN IIAL B0IIDING 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, 25S33 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 FINALCERTIFICATI! OF oa:tlPANCY MAYNOf BElSSUED AITERJIILY I, 1989 UNLESS TIIEAPPUCANT
HAS M1IT OR IS MmllNG 111E REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND 111E AIR POLLUTION CDN1ROL DISl1UCT.
9. WNSl'RUCIION LENDING AGENCY
I hereby afhrm that there 1s a construction lend mg agency for the performance of the work for which this permit 1s 1~ued (Sec 3097 (a) CivU Code).
LENDER'S NAME LENDER'S ADDRESS
IO. APPUCAN I CPJt I ll'ICAliON
I certify that I have read the apphcatmn and state that the aOOve mformauon 1s correct. I agree to comply with ail City ordmances and State laws
relating co building construction. I hereby authorize representatives of the City of Carlsbad to enter upon the above mentioned property for inspection
purposes. I Al.'lO AGREE ID SAVE INDEMNIFY AND KEEP II.ARMLESS 11IE CITY OF CARISBAD AGAINST AIL UABillTIES, JllllGMENTS, cnsrs
AND EXPENSES WIDCH MAY IN ANY WAY ACDUJE AGAINST SAID CITY IN CDNSEQIJENCE OF 1llE GRANTING OF TilIS 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 365 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 303(d) Uniform Buiwtg Code).
APPr;:Tr:N~TIJRE Cr~ -DATE: f/(?5rl I
..., ~ UQ. ~TE: File YEIJ.OW: Applicant PINK: Finance