HomeMy WebLinkAbout2809 CARLSBAD VILLAGE DR; ; 84-205; PermitDECLARATIONS
LENDER WORKER S COMPENSATION OWNER/BUILDER CONTRACTORr
1 onrtor c MjmflQ 1 hereby atiirm thai mere is a con"! rue lionlending agency tor 'rip pertarmanre ol he wor* lor'*hicn this permit is issued (Sec 3097 Cml Code)COMPANYn Copy is died with Ihe cityD Certified copy is hereby lurmsdedCERTIFICAH OF EXEMPTION FROMWORKERS COMPENSATION INSURANCE(This section need nol be completed <l Ihe permitis. 'or one hundred dollars (1100) or lesslQ 1 certily that in Ihe perlormance of the *ork forv which this permit is issued 1 shall nol employ anyperson <n any manner so as to t>ecome subiect lothe Workers Compensation La*s of CdlilomtdNOTICE TO APPLICANT If alter making Ihis Cerli 'ficale of Exemption you snould fcome subject I >the Workers Compensation provisions ol the LaoorCode you musl lorth^ith comply with suchprovisions OJ this permil shall OP deemed revokedQ 1 hereby attirm thai I ha*e a cerlificate ol conseniLo self insure or a cenificale ol WorKersCompensalion Insurance or a Cprtilied copy Iheieol(Sec 3800 Labor Code)POLICY NOfor ihis reason^ ,2 D ETS ^^"c'sp "^*^o.3^"D3^Si
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* a. ST ° • a. 2-2 g1 2 -~"^ Sg'S^^^SSS licensed pursuant to the provisions ot the Lonuacior sLicense Law (Chanter 9 commencing with Section 7000 olDivision 3 ol Ihe Business afltf Professions Code) or |hal is eiempl Itierelrom and ihe oasis for the alleged eiemption Anyviolalicn_ol Section 7031 5 by an applicant lor a peimil sub[eels in e applicant to a civil penally of nol more than livehundred dollars (S50G)1 J 1 as owner of Ihe property or my employees with wagest~1 tiereoy affirm Ida! 1 am eiempt from the Conlrac(or s License Law lor IKs to/totcing feason (Sec 7031 5Business and Prolessions Code Any city or county which reouires a permiMo construct alter improve demolish' orrepau any structure prior to its issuance also requires 'he applicanl lor such permit to file a siqned slalernenl that he is.Q 1 hereby aftirm thai 1 am licensed underprovisions of Chapter 9 (commencing withSection 7000) of Division 3 of the Businessand Professions Code, and my license is infull force and effect"l,r Mr, flay;STRUCTTCW WHEFHEft SHtUHMJ HEREIN ORNOI 4 ALSO AUHbb IO SAVt iNUbMNJH ANU APPUCANT «, c,«NATi IRF *_ <-,«,,.«: bO f niaTRAOTno HKEEP HARMLESS THE CITY OF CAR1SBAO AGAINST ALL LABILITIES JUDGMENTS COSTS ANO APPL!CANT S SIGNATURED OWNER LJ CONTRACTOR UEXPENSES WHJOiH MAY IN ANY WAY ACCRUE AGAINST SAtD CITY iN CONSEQUENCE OF THE ^ . - /^ /^ J$rf. BY PHONP DGRANTING OF THIS PERMiT %£/ • X / ^^l&G^T^TJ
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^L^CERTIFY UNDER PEN^rTTOF PERJURY THAT ALL INFORMATION HEREON INCLUDING THEOECLARATIONS ARE TRUE AWD CORRECT AND i FURTHER GERIiFY AND AGREE tF A PERMIT l&ISSy&D TO CQMPLY WiTH AU, C(TY COUM1Y AMD STATE LAWS GQVERNiNG 8UILDINC3 COW-"•
\Expiration E»efV permit issued by the By il(Code shall expire by limitation and becomeauthorized by such permit is riot commencepermtt ot if Ille building or work aulhoriabanQonad at any ttme after ttie work is coring OUjctal errder the previsions ol ttiinulta«dvo!c! It the burlding or worJ wttdtn 1 80 days from the date ot sueloo by such permit ts si^psrfJed onmenced (or a oeood Of 180 da^s5 0 DEEP ANQ DEMOLITION OSTflUCTURES OVER 3 STORIESR CONSTRUCTION Qf 1IN HEIGHTt-
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\f zV 1 CARLSBAD BUILDING DEPARTMENT APPLICATION & PEF1200 Elm, Carlsbad California 92008 1989 [619)4385525USE BALL POINT PEN ONLY & PRESS HARD APPLICANT TO FILL IN INFORMATION WITHIN SHADED AREA AND OECLARATIONSWhite — Inspector Green — (1) Finance (2) Data Process Yellow — Assessor Pmkr-i-^pphcant Gold — Temporary File
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