The URL can be used to link to this page

Home My WebLink About2852 CAMINO SERBAL; ; CB051456; Permit04^5-2005 City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 Miscellaneous Permit Permit No: CB051456 Building Inspection Request Line (760) 602-2725 Job Address: Permit Type: Parcel No: Valuation: Reference #: 2852 CAMINO SERBAL CBAD MISC 2552812500 $3,157.00 Subtype: Lot #: OTHER 0 SHAFFER RES 9FT OUTDOOR FIREPLACE Status: Applied: Entered By: Plan Approved: Issued: Inspect Area: ISSUED 04/25/2005 KG 04/25/2005 04/25/2005 iSUJ^SgTDR ENCINITASCA 92024 760 942-2796 Owner: SHAFFER STEVEN J&AMY C REVOCABLE TRUST 03-16-04 2852 CAMINO SERBAL CARLSBAD CA 92009 Miscelaneous Fee #1 Miscelaneous Fee #2 Additional Fees TOTAL PERMIT FEES PERMIT $89.00 $0.00 $0.00 $89.00 Total Fees:$89.00 Total Payments To Date:$0.00 Balance Due:$89.00 04/25/05 0002 01 CGF" 02 89-00 BUILDING PLANS STORAGE ATTACHED Inspector:-JU.FINAL APj Date:Clearance: NOTICE: Please take NOTICE that approval of your project includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter collectively referred to as "fees/exactions." You 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 Government 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 Dreviouslv been aiven aMCTJCE similar to this, or as to which the statute of limitations has previously otherwise expired. PERMIT APPLICATION CITY OF CARLSBAD BUILDING DEPARTMENT 1635 Faraday Ave., Carlsbad, CA 92008 t. PROJECT INFORMATION FOR OFFICE USE ONLY PLAN CHECK EST. VAL. Plan Ck. Deposit Validated By Date Address (include Bldg/Suite #)Business Name (at this address) Legal Description Lot No.Subdivision Name/Number Unit No.Phase No.Total # of units Assessor's Parcel #Existing Use Proposed Use Description of Work Sd. FT.#of Stories # of Bedrooms # of Bathrooms 2. CONTACT i applicant) Name Address City 3. APPLICANT Q"contractor D Agent for Contractor C3 Owner D Agent for Owner State/Zip Telephone # Fax # Name 4. PROPERTY OWNER Address City State/Zip Telephone Name 6. CONTRACTOR - COMPANY NAME Address City State/Zip 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 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 exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than fiye hundred dollars l$500j).THE. Name State License Address License Class _ t- 7 City State/Zip City Business License # ( i-O Telephone ff Designer Name Address City State/Zip Telephone State License # 6. WORKERS'COMPENSATION Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations: Gf 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. (~1 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. My worker's compensation insurance carrier and policy number are: . Insurance Company ^TATE f U MP Policy No. \1^3>~2l^ - Z£%5>4~ Expiration Date O~f//£,l/Z^>£>^' (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS [$100] OR LESS) ' < [~) 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. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor code, interest and attorney's fees. SIGNATURE DATE 7, OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law 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). l~l 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). Q I am exempt under Section Business and Professions Code for this reason: 1. I personally plan to provide the major labor and materials for construction of the proposed property improvement. Q YES [UNO 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 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? l~l YES Q NO Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? f~l YES l~l NO Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? Q YES Q 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. 9. 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. 3097(i) Civil Code). LENDER'S NAME LENDER'S ADDRESS 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. 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 i EXPIRATION: Every permit issued by. authorized by such permit is not c at any time after the work is ( APPLICANT'S SIGNATURE pns over 5'0" deep and demolition or construction of structures over 3 stories in height. ifrig OfficicjLufwter the provisions of this Code shall expire by limitation and become null and void if the building or work rithin>6lJ"3ays from the date of such permit or if the building or work authorized by such permit is suspended or abandoned Sriod of 180 days (Section 106.4.4 Uniform Building Code). DATE WHITE: File YELLOW: Applicant PINK: Finance 7 ( City of Carlsbad Bldg Inspection Request For: 07/01/2005 Permit* CB051456 Inspector Assignment: JM Title: SHAFFER RES 9FT OUTDOOR Description: FIREPLACE Type:MISC Sub Type: OTHER Phone: 7607178358 Job Address: 2852 CAMINO SERBAL Suite: Lot 0 Location: Inspector: APPLICANT THE PALM CO Owner: SHAFFER STEVEN J&AMY C REVOCABLE TRUST 03-16-04 Remarks: Total Time: Requested By: PAUL Entered By: CHRISTINE CD Description Act Comment 19 Final Structural P>^ Associated PCRs/CVs Inspection History Date Description Act Insp Comments 05/10/2005 62 Steel/Bond Beam AP JM OK TO GROUT FIREPLACE 05/09/2005 62 Steel/Bond Beam CA JM PAUL 04/26/2005 11 Ftg/Foundation/Piers AP PY SD POLICYHOLDER COPY ,-- r-r P.O. Bt)X SO?) SAN FRAIMCISCO,CA 94142-0807CQMPBNSATIOM \ 'NS'UFtANGK FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE O7-01-2004 A ? * GROUP: POLICY NUMBER: 1733719-2004 CERTIFICATE MX 2 CERTIFICATE EXPIRES: 07-01-2005 f ; \ i O7-01-i2Op4/67"O1-2OO5 CONTRACTORS STATE LICENSE BOARD SD ; LICENSE NUMBER: #660724 WORKERS;': COMPENSATION UNIT INCEPTION DATE: 07-O1-2004 ,/ P 0 BOX 26000 ; ? ••" D.O.: SO SACRAMENTO CA 95iB26 i i ^ 'i i \ This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein-LNqtwrithstandin^ any requirenw't. term, or condition of any contract or btherr documentwith respect to which this certificate of insurance may t>e issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. : AUTHORIZED REPRESENTATIVE PRESIDENT; EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,OOO,OOO,OO PER OCCURRENCE. EMPLOYER LEGUU. NAME THE PALM COMPANY f TWTOt5ETHER, LLC AND/OR 395 SUNSET DR j ) : ' COOMES, CARt DOUGLASTAND ENCINITAS CA 92024 COOMES, JOANNE _ OB/17/20O4 * 6o 3 a •> ti sX- SM £V -- •X "& ,•*\ / N -.-¥ ^-^ \\v_- p y^I % feV3 U ^ '*SUf 3 ^A 3T~C« *Lu ^ ^VL V 'u . /v. I ^fc- ^ ovA ^^ — i— n\ 2^-^^> ' 1 \/